Procedure codes
Index
Copyright
Introduction
5 - Ear, nose and throat
5.3 - Inner ear
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
14 - Female reproductive organs
14.5 - Vulva/labia
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
10 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
14 - Female reproductive organs
14.1 - Uterus/adnexa
14.4 - Vagina/perineum
12 - Urinary system and male reproductive organs
12.3 - Bladder
15 - Skin and subcutaneous tissue
15.2 - Repair
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
4 - Eye and orbital contents
4.5 - Conjuctiva
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
17 - Interventional radiology
17.11 - Liver
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
12 - Urinary system and male reproductive organs
12.2 - Ureter
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.2 - Eyebrow and lid
4.6 - Cornea
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
9 - Vascular system
9.5 - Ileo-femoral vessels
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
4 - Eye and orbital contents
4.6 - Cornea
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
7 - Breast
7.4 - Other
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
2 - Brain, cranium and intracranial organs
2.4 - Nerves
12 - Urinary system and male reproductive organs
12.4 - Urethra
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
14 - Female reproductive organs
14.3 - Cervix uteri
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
14 - Female reproductive organs
14.2 - Suspension
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
2 - Brain, cranium and intracranial organs
2.3 - Meninges
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.7 - Shoulder
5 - Ear, nose and throat
5.3 - Inner ear
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
6 - Face, mouth, salivary and thyroid
6.4 - Palate
5 - Ear, nose and throat
5.1 - External ear
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.1 - External ear
12 - Urinary system and male reproductive organs
12.6 - Genitalia
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
14 - Female reproductive organs
14.4 - Vagina/perineum
2 - Brain, cranium and intracranial organs
2.3 - Meninges
6 - Face, mouth, salivary and thyroid
6.2 - Lips
12 - Urinary system and male reproductive organs
12.4 - Urethra
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
2 - Brain, cranium and intracranial organs
2.5 - Vessels
4 - Eye and orbital contents
4.12 - General
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
12 - Urinary system and male reproductive organs
12.4 - Urethra
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
9 - Vascular system
9.6 - Non-specific
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
4 - Eye and orbital contents
4.2 - Eyebrow and lid
17 - Interventional radiology
17.3 - Angioplasty
17.8 - Spine
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
4 - Eye and orbital contents
4.3 - Lacrimal system
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
15.2 - Repair
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
3.6 - Peripheral nerves
3.6 - Peripheral nerves
5 - Ear, nose and throat
5.5 - Nasal sinuses
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
4 - Eye and orbital contents
4.2 - Eyebrow and lid
4.5 - Conjuctiva
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.6 - Rectum/anus
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
5 - Ear, nose and throat
5.3 - Inner ear
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
9 - Vascular system
9.8 - Lymphatic system
5 - Ear, nose and throat
5.1 - External ear
17 - Interventional radiology
17.4 - Embolisation
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
9 - Vascular system
9.1 - Head and neck
9.2 - Thoracic vessels
5 - Ear, nose and throat
5.6 - Throat
17 - Interventional radiology
17.12 - Urinary
7 - Breast
7.3 - Reconstruction
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
5 - Ear, nose and throat
5.7 - Larynx and trachea
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.7 - Shoulder
16.11 - Foot
17 - Interventional radiology
17.13 - Other
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
2 - Brain, cranium and intracranial organs
2.1 - Brain
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
9 - Vascular system
9.5 - Ileo-femoral vessels
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
5 - Ear, nose and throat
5.1 - External ear
2 - Brain, cranium and intracranial organs
2.6 - Other
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
3.8 - Other procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.8 - Major vessels
17 - Interventional radiology
17.4 - Embolisation
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.4 - Small intestine
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
9 - Vascular system
9.7 - Varicose veins
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
2 - Brain, cranium and intracranial organs
2.1 - Brain
4 - Eye and orbital contents
4.4 - Muscles
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
6 - Face, mouth, salivary and thyroid
6.4 - Palate
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
14 - Female reproductive organs
14.1 - Uterus/adnexa
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
4 - Eye and orbital contents
4.3 - Lacrimal system
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
5 - Ear, nose and throat
5.6 - Throat
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
8.4 - Fibreoptic endoscopic procedures (GA or LA)
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
17 - Interventional radiology
17.3 - Angioplasty
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
5 - Ear, nose and throat
5.7 - Larynx and trachea
17 - Interventional radiology
17.8 - Spine
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.6 - Cornea
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
9 - Vascular system
9.2 - Thoracic vessels
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
17 - Interventional radiology
17.6 - Dilatation
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.7 - Shoulder
5 - Ear, nose and throat
5.7 - Larynx and trachea
7 - Breast
7.4 - Other
9 - Vascular system
9.8 - Lymphatic system
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
8.11 - Other
2 - Brain, cranium and intracranial organs
2.1 - Brain
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.4 - Palate
14 - Female reproductive organs
14.1 - Uterus/adnexa
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
16.11 - Foot
15 - Skin and subcutaneous tissue
15.2 - Repair
17 - Interventional radiology
17.12 - Urinary
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
9 - Vascular system
9.2 - Thoracic vessels
17 - Interventional radiology
17.3 - Angioplasty
9 - Vascular system
9.8 - Lymphatic system
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
6 - Face, mouth, salivary and thyroid
6.2 - Lips
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
9 - Vascular system
9.5 - Ileo-femoral vessels
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
5 - Ear, nose and throat
5.5 - Nasal sinuses
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.6 - Peripheral nerves
8 - Thorax and intra-thoracic organs
8.11 - Other
5 - Ear, nose and throat
5.7 - Larynx and trachea
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
14 - Female reproductive organs
14.1 - Uterus/adnexa
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
4 - Eye and orbital contents
4.11 - Retina
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.9 - Abdominal wall
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
2 - Brain, cranium and intracranial organs
2.4 - Nerves
14 - Female reproductive organs
14.1 - Uterus/adnexa
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
12 - Urinary system and male reproductive organs
12.3 - Bladder
12.4 - Urethra
12.6 - Genitalia
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.7 - Larynx and trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
9 - Vascular system
9.7 - Varicose veins
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
12 - Urinary system and male reproductive organs
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
8 - Thorax and intra-thoracic organs
8.11 - Other
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.8 - Neck
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
4 - Eye and orbital contents
4.4 - Muscles
6 - Face, mouth, salivary and thyroid
6.8 - Neck
4 - Eye and orbital contents
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
16.12 - External fixation/traction
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
4 - Eye and orbital contents
4.5 - Conjuctiva
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
4 - Eye and orbital contents
4.5 - Conjuctiva
2 - Brain, cranium and intracranial organs
2.4 - Nerves
7 - Breast
7.3 - Reconstruction
8 - Thorax and intra-thoracic organs
8.3 - Trachea
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
8 - Thorax and intra-thoracic organs
8.11 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
9 - Vascular system
9.1 - Head and neck
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
16.13 - Amputation
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
12 - Urinary system and male reproductive organs
12.3 - Bladder
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.4 - Urethra
4 - Eye and orbital contents
4.1 - Globe and orbit
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.4 - Muscles
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
4 - Eye and orbital contents
4.2 - Eyebrow and lid
12 - Urinary system and male reproductive organs
12.3 - Bladder
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.12 - External fixation/traction
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.3 - Lacrimal system
9 - Vascular system
9.8 - Lymphatic system
17 - Interventional radiology
17.13 - Other
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
12 - Urinary system and male reproductive organs
12.2 - Ureter
14 - Female reproductive organs
14.5 - Vulva/labia
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
9 - Vascular system
9.2 - Thoracic vessels
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.5 - Prostate
9 - Vascular system
9.7 - Varicose veins
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
9 - Vascular system
9.5 - Ileo-femoral vessels
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.5 - Prostate
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
15 - Skin and subcutaneous tissue
15.2 - Repair
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
11.7 - Other organs (mainly digestive)
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
12 - Urinary system and male reproductive organs
12.4 - Urethra
4 - Eye and orbital contents
4.6 - Cornea
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
7 - Breast
7.1 - Excision/biopsy codes
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
2 - Brain, cranium and intracranial organs
2.2 - Cranium
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
12 - Urinary system and male reproductive organs
12.2 - Ureter
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
12 - Urinary system and male reproductive organs
12.6 - Genitalia
9 - Vascular system
9.7 - Varicose veins
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
11.10 - Peritoneum
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
9 - Vascular system
9.2 - Thoracic vessels
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.7 - Other organs (mainly digestive)
9 - Vascular system
9.6 - Non-specific
7 - Breast
7.3 - Reconstruction
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
5.6 - Throat
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
4 - Eye and orbital contents
4.4 - Muscles
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
5 - Ear, nose and throat
5.6 - Throat
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.5 - Prostate
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
4 - Eye and orbital contents
4.12 - General
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.3 - Fractures
16.7 - Shoulder
17 - Interventional radiology
17.8 - Spine
7 - Breast
7.3 - Reconstruction
2 - Brain, cranium and intracranial organs
2.1 - Brain
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
12 - Urinary system and male reproductive organs
12.4 - Urethra
12.6 - Genitalia
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
2 - Brain, cranium and intracranial organs
2.6 - Other
5 - Ear, nose and throat
5.5 - Nasal sinuses
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
14 - Female reproductive organs
14.5 - Vulva/labia
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
5 - Ear, nose and throat
5.5 - Nasal sinuses
9 - Vascular system
9.7 - Varicose veins
12 - Urinary system and male reproductive organs
12.4 - Urethra
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.12 - External fixation/traction
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
4 - Eye and orbital contents
4.10 - Vitreous
12 - Urinary system and male reproductive organs
12.3 - Bladder
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
7 - Breast
7.3 - Reconstruction
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.9 - Heart – cardiology
2 - Brain, cranium and intracranial organs
2.1 - Brain
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
6.7 - Teeth
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.10 - Knee
14 - Female reproductive organs
14.4 - Vagina/perineum
4 - Eye and orbital contents
4.4 - Muscles
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
17 - Interventional radiology
17.4 - Embolisation
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.6 - Peripheral nerves
5 - Ear, nose and throat
5.1 - External ear
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
16.11 - Foot
16.13 - Amputation
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
17 - Interventional radiology
17.6 - Dilatation
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
5 - Ear, nose and throat
5.5 - Nasal sinuses
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
9 - Vascular system
9.5 - Ileo-femoral vessels
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.9 - Neurophysiological procedures
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
12 - Urinary system and male reproductive organs
12.2 - Ureter
17 - Interventional radiology
17.1 - Biopsy
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
14 - Female reproductive organs
14.4 - Vagina/perineum
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
2 - Brain, cranium and intracranial organs
2.2 - Cranium
9 - Vascular system
9.6 - Non-specific
14 - Female reproductive organs
14.1 - Uterus/adnexa
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
4 - Eye and orbital contents
4.3 - Lacrimal system
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.3 - Bladder
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
14 - Female reproductive organs
14.1 - Uterus/adnexa
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
9 - Vascular system
9.6 - Non-specific
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
4 - Eye and orbital contents
4.4 - Muscles
17 - Interventional radiology
17.13 - Other
12 - Urinary system and male reproductive organs
12.2 - Ureter
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
4 - Eye and orbital contents
4.3 - Lacrimal system
5 - Ear, nose and throat
5.5 - Nasal sinuses
14 - Female reproductive organs
14.1 - Uterus/adnexa
14.4 - Vagina/perineum
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.3 - Bladder
2 - Brain, cranium and intracranial organs
2.5 - Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
4 - Eye and orbital contents
4.2 - Eyebrow and lid
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.10 - Peritoneum
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.6 - Genitalia
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
9 - Vascular system
9.4 - Abdominal vessels
12 - Urinary system and male reproductive organs
12.3 - Bladder
9 - Vascular system
9.7 - Varicose veins
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
9 - Vascular system
9.5 - Ileo-femoral vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
12 - Urinary system and male reproductive organs
12.5 - Prostate
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
9 - Vascular system
9.6 - Non-specific
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
9 - Vascular system
9.2 - Thoracic vessels
12 - Urinary system and male reproductive organs
12.5 - Prostate
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.3 - Fractures
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
12 - Urinary system and male reproductive organs
12.5 - Prostate
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.2 - Ureter
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
12 - Urinary system and male reproductive organs
12.4 - Urethra
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
8 - Thorax and intra-thoracic organs
8.3 - Trachea
8.10 - Great Vessels
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
12 - Urinary system and male reproductive organs
12.4 - Urethra
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.2 - Lips
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
5 - Ear, nose and throat
5.5 - Nasal sinuses
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
14 - Female reproductive organs
14.1 - Uterus/adnexa
4 - Eye and orbital contents
4.12 - General
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
2 - Brain, cranium and intracranial organs
2.2 - Cranium
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
9 - Vascular system
9.6 - Non-specific
9.7 - Varicose veins
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
15.2 - Repair
15.3 - Burns, scars and contractures
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
4 - Eye and orbital contents
4.10 - Vitreous
5 - Ear, nose and throat
5.5 - Nasal sinuses
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.4 - Small intestine
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
9 - Vascular system
9.6 - Non-specific
5 - Ear, nose and throat
5.7 - Larynx and trachea
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
9 - Vascular system
9.2 - Thoracic vessels
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
7 - Breast
7.4 - Other
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
9 - Vascular system
9.5 - Ileo-femoral vessels
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.4 - Urethra
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
2 - Brain, cranium and intracranial organs
2.5 - Vessels
9 - Vascular system
9.5 - Ileo-femoral vessels
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
17 - Interventional radiology
17.1 - Biopsy
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
4 - Eye and orbital contents
4.3 - Lacrimal system
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
14 - Female reproductive organs
14.2 - Suspension
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
17 - Interventional radiology
17.11 - Liver
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
18 - Chemotherapy
18.0 - Chemotherapy
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
4 - Eye and orbital contents
4.9 - Lens
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
5 - Ear, nose and throat
5.5 - Nasal sinuses
14 - Female reproductive organs
14.3 - Cervix uteri
17 - Interventional radiology
17.9 - Thorax
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
14 - Female reproductive organs
14.4 - Vagina/perineum
9 - Vascular system
9.4 - Abdominal vessels
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
15 - Skin and subcutaneous tissue
15.2 - Repair
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
12 - Urinary system and male reproductive organs
12.5 - Prostate
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
17 - Interventional radiology
17.1 - Biopsy
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
14 - Female reproductive organs
14.1 - Uterus/adnexa
5 - Ear, nose and throat
5.3 - Inner ear
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
9 - Vascular system
9.4 - Abdominal vessels
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
14 - Female reproductive organs
14.4 - Vagina/perineum
12 - Urinary system and male reproductive organs
12.4 - Urethra
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
5 - Ear, nose and throat
5.1 - External ear
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
12 - Urinary system and male reproductive organs
12.2 - Ureter
5 - Ear, nose and throat
5.7 - Larynx and trachea
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.3 - Bladder
17 - Interventional radiology
17.3 - Angioplasty
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.9 - Lens
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.1 - Globe and orbit
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
9 - Vascular system
9.7 - Varicose veins
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
14 - Female reproductive organs
14.1 - Uterus/adnexa
17 - Interventional radiology
17.13 - Other
14 - Female reproductive organs
14.3 - Cervix uteri
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
2 - Brain, cranium and intracranial organs
2.3 - Meninges
12 - Urinary system and male reproductive organs
12.2 - Ureter
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
14 - Female reproductive organs
14.1 - Uterus/adnexa
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
7.4 - Other
17 - Interventional radiology
17.1 - Biopsy
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
9 - Vascular system
9.6 - Non-specific
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
12 - Urinary system and male reproductive organs
12.3 - Bladder
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
2 - Brain, cranium and intracranial organs
2.2 - Cranium
12 - Urinary system and male reproductive organs
12.6 - Genitalia
9 - Vascular system
9.8 - Lymphatic system
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
7 - Breast
7.4 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
4 - Eye and orbital contents
4.7 - Sclera
6 - Face, mouth, salivary and thyroid
6.2 - Lips
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
12 - Urinary system and male reproductive organs
12.3 - Bladder
15 - Skin and subcutaneous tissue
15.2 - Repair
4 - Eye and orbital contents
4.6 - Cornea
5 - Ear, nose and throat
5.5 - Nasal sinuses
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.12 - External fixation/traction
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.10 - Knee
9 - Vascular system
9.4 - Abdominal vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
9 - Vascular system
9.6 - Non-specific
17 - Interventional radiology
17.13 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
14 - Female reproductive organs
14.2 - Suspension
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
2 - Brain, cranium and intracranial organs
2.1 - Brain
9 - Vascular system
9.7 - Varicose veins
7 - Breast
7.3 - Reconstruction
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
11.7 - Other organs (mainly digestive)
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
4 - Eye and orbital contents
4.2 - Eyebrow and lid
4.10 - Vitreous
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.5 - Nasal sinuses
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.6 - Hand
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
14 - Female reproductive organs
14.4 - Vagina/perineum
5 - Ear, nose and throat
5.6 - Throat
14 - Female reproductive organs
14.4 - Vagina/perineum
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.2 - Lips
15 - Skin and subcutaneous tissue
15.2 - Repair
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
3.3 - Paraspinal injections
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
22 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
4 - Eye and orbital contents
4.1 - Globe and orbit
4.5 - Conjuctiva
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
16.11 - Foot
16.13 - Amputation
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.6 - Hand
16.10 - Knee
5 - Ear, nose and throat
5.7 - Larynx and trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
2 - Brain, cranium and intracranial organs
2.1 - Brain
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
7 - Breast
7.1 - Excision/biopsy codes
9 - Vascular system
9.5 - Ileo-femoral vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.12 - External fixation/traction
22 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
9 - Vascular system
9.8 - Lymphatic system
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
14 - Female reproductive organs
14.3 - Cervix uteri
6 - Face, mouth, salivary and thyroid
6.4 - Palate
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.4 - Nerves
9 - Vascular system
9.8 - Lymphatic system
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
18 - Chemotherapy
18.0 - Chemotherapy
9 - Vascular system
9.7 - Varicose veins
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
14 - Female reproductive organs
14.2 - Suspension
12 - Urinary system and male reproductive organs
12.4 - Urethra
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.12 - External fixation/traction
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.9 - Lens
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
9 - Vascular system
9.1 - Head and neck
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
5 - Ear, nose and throat
5.1 - External ear
4 - Eye and orbital contents
4.5 - Conjuctiva
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
4 - Eye and orbital contents
4.2 - Eyebrow and lid
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
9 - Vascular system
9.7 - Varicose veins
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.7 - Larynx and trachea
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.7 - Sclera
9 - Vascular system
9.6 - Non-specific
4 - Eye and orbital contents
4.3 - Lacrimal system
4.4 - Muscles
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
7 - Breast
7.4 - Other
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
4 - Eye and orbital contents
4.3 - Lacrimal system
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
4 - Eye and orbital contents
4.11 - Retina
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
4 - Eye and orbital contents
4.10 - Vitreous
7 - Breast
7.1 - Excision/biopsy codes
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
4 - Eye and orbital contents
4.5 - Conjuctiva
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.2 - Eyebrow and lid
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
14 - Female reproductive organs
14.1 - Uterus/adnexa
17 - Interventional radiology
17.11 - Liver
2 - Brain, cranium and intracranial organs
2.3 - Meninges
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
4 - Eye and orbital contents
4.2 - Eyebrow and lid
14 - Female reproductive organs
14.4 - Vagina/perineum
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
17 - Interventional radiology
17.1 - Biopsy
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
14 - Female reproductive organs
14.1 - Uterus/adnexa
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
2 - Brain, cranium and intracranial organs
2.4 - Nerves
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
17 - Interventional radiology
17.3 - Angioplasty
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
5 - Ear, nose and throat
5.7 - Larynx and trachea
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
16.10 - Knee
4 - Eye and orbital contents
4.7 - Sclera
9 - Vascular system
9.2 - Thoracic vessels
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
22 - Gender Affirmation
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.3 - Bladder
17 - Interventional radiology
17.13 - Other
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
9 - Vascular system
9.1 - Head and neck
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
12 - Urinary system and male reproductive organs
12.3 - Bladder
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.5 - Practitioner and Therapist fees
4 - Eye and orbital contents
4.10 - Vitreous
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
9 - Vascular system
9.6 - Non-specific
5 - Ear, nose and throat
5.6 - Throat
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
18 - Chemotherapy
18.0 - Chemotherapy
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
19 - Haematology (Hospital Use Only)
19.2 - Stem Cell
14 - Female reproductive organs
14.1 - Uterus/adnexa
2 - Brain, cranium and intracranial organs
2.1 - Brain
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
22 - Gender Affirmation
12 - Urinary system and male reproductive organs
12.2 - Ureter
14 - Female reproductive organs
14.1 - Uterus/adnexa
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
5 - Ear, nose and throat
5.5 - Nasal sinuses
12 - Urinary system and male reproductive organs
12.5 - Prostate
12.5 - Prostate
12.6 - Genitalia
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
17 - Interventional radiology
17.1 - Biopsy
12 - Urinary system and male reproductive organs
12.4 - Urethra
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
7 - Breast
7.4 - Other
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.7 - Shoulder
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.9 - Hip, leg and pelvis
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
22 - Gender Affirmation
20 - Radiotherapy
20.0 - Radiotherapy
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
4 - Eye and orbital contents
4.1 - Globe and orbit
9 - Vascular system
9.5 - Ileo-femoral vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
4 - Eye and orbital contents
4.9 - Lens
19 - Haematology (Hospital Use Only)
19.2 - Stem Cell
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.10 - Knee
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
17 - Interventional radiology
17.8 - Spine
5 - Ear, nose and throat
5.3 - Inner ear
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
7 - Breast
7.1 - Excision/biopsy codes
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
17 - Interventional radiology
17.9 - Thorax
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
14 - Female reproductive organs
14.1 - Uterus/adnexa
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
4 - Eye and orbital contents
4.6 - Cornea
14 - Female reproductive organs
14.2 - Suspension
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
8.5 - Bronchi/lungs/pleura
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
6 - Face, mouth, salivary and thyroid
6.4 - Palate
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.11 - Other
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
18 - Chemotherapy
18.0 - Chemotherapy
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
2 - Brain, cranium and intracranial organs
2.1 - Brain
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
7 - Breast
7.3 - Reconstruction
17 - Interventional radiology
17.10 - Gastrointestinal
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
2 - Brain, cranium and intracranial organs
2.1 - Brain
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
17 - Interventional radiology
17.13 - Other
12 - Urinary system and male reproductive organs
12.4 - Urethra
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
4 - Eye and orbital contents
4.6 - Cornea
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
2 - Brain, cranium and intracranial organs
2.2 - Cranium
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
6 - Face, mouth, salivary and thyroid
6.2 - Lips
2 - Brain, cranium and intracranial organs
2.2 - Cranium
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
22 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
20 - Radiotherapy
20.0 - Radiotherapy
4 - Eye and orbital contents
4.9 - Lens
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
20 - Radiotherapy
20.0 - Radiotherapy
4 - Eye and orbital contents
4.5 - Conjuctiva
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
22 - Gender Affirmation
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
22 - Gender Affirmation
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
14 - Female reproductive organs
14.1 - Uterus/adnexa
4 - Eye and orbital contents
4.1 - Globe and orbit
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
9 - Vascular system
9.5 - Ileo-femoral vessels
22 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
17 - Interventional radiology
17.7 - Head and neck
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
4 - Eye and orbital contents
4.6 - Cornea
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
20 - Radiotherapy
20.0 - Radiotherapy
4 - Eye and orbital contents
4.9 - Lens
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
4 - Eye and orbital contents
4.1 - Globe and orbit
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
8 - Thorax and intra-thoracic organs
8.3 - Trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
14 - Female reproductive organs
14.4 - Vagina/perineum
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
9 - Vascular system
9.8 - Lymphatic system
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
14 - Female reproductive organs
14.5 - Vulva/labia
22 - Gender Affirmation
14 - Female reproductive organs
14.2 - Suspension
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
12 - Urinary system and male reproductive organs
12.5 - Prostate
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.7 - Shoulder
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.9 - Hip, leg and pelvis
16.11 - Foot
22 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
17 - Interventional radiology
17.10 - Gastrointestinal
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
22 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
5 - Ear, nose and throat
5.6 - Throat
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.3 - Bladder
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.4 - Urethra
17 - Interventional radiology
17.1 - Biopsy
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
22 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
20 - Radiotherapy
20.0 - Radiotherapy
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
12 - Urinary system and male reproductive organs
12.5 - Prostate
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
14 - Female reproductive organs
14.2 - Suspension
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
9 - Vascular system
9.5 - Ileo-femoral vessels
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
9 - Vascular system
9.7 - Varicose veins
14 - Female reproductive organs
14.1 - Uterus/adnexa
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.6 - Hand
16.11 - Foot
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
17 - Interventional radiology
17.4 - Embolisation
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
12 - Urinary system and male reproductive organs
12.4 - Urethra
20 - Radiotherapy
20.0 - Radiotherapy
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
7 - Breast
7.3 - Reconstruction
20 - Radiotherapy
20.0 - Radiotherapy
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
4 - Eye and orbital contents
4.11 - Retina
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
4 - Eye and orbital contents
4.1 - Globe and orbit
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
9 - Vascular system
9.8 - Lymphatic system
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
4 - Eye and orbital contents
4.3 - Lacrimal system
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.3 - Bladder
14 - Female reproductive organs
14.3 - Cervix uteri
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
12 - Urinary system and male reproductive organs
12.5 - Prostate
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
7 - Breast
7.1 - Excision/biopsy codes
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
7 - Breast
7.3 - Reconstruction
19 - Haematology (Hospital Use Only)
19.2 - Stem Cell
22 - Gender Affirmation
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
9 - Vascular system
9.2 - Thoracic vessels
4 - Eye and orbital contents
4.10 - Vitreous
12 - Urinary system and male reproductive organs
12.3 - Bladder
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.10 - Knee
19 - Haematology (Hospital Use Only)
19.2 - Stem Cell
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
12 - Urinary system and male reproductive organs
12.3 - Bladder
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
5 - Ear, nose and throat
5.5 - Nasal sinuses
4 - Eye and orbital contents
4.1 - Globe and orbit
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
22 - Gender Affirmation
22.0 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.9 - Heart – cardiology
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
16.10 - Knee
19 - Haematology (Hospital Use Only)
19.2 - Stem Cell
2 - Brain, cranium and intracranial organs
2.1 - Brain
22 - Gender Affirmation
22.0 - Gender Affirmation
20 - Radiotherapy
20.0 - Radiotherapy
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
11 - Abdomen (excluding urinary and reproductive organs)
11.0 - Abdomen (excluding urinary and reproductive organs)
7 - Breast
7.4 - Other
4 - Eye and orbital contents
4.2 - Eyebrow and lid
14 - Female reproductive organs
14.4 - Vagina/perineum
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
18 - Chemotherapy
18.0 - Chemotherapy
22 - Gender Affirmation
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
22 - Gender Affirmation
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
22 - Gender Affirmation
5 - Ear, nose and throat
5.6 - Throat
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
5 - Ear, nose and throat
5.6 - Throat
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
9 - Vascular system
9.7 - Varicose veins
12 - Urinary system and male reproductive organs
12.3 - Bladder
19 - Haematology (Hospital Use Only)
19.1 - Bone Marrow
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
22 - Gender Affirmation
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
9 - Vascular system
9.6 - Non-specific
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
16.10 - Knee
19 - Haematology (Hospital Use Only)
19.1 - Bone Marrow
19.2 - Stem Cell
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
22 - Gender Affirmation
7 - Breast
7.3 - Reconstruction
2 - Brain, cranium and intracranial organs
2.1 - Brain
12 - Urinary system and male reproductive organs
12.3 - Bladder
9 - Vascular system
9.6 - Non-specific
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
2 - Brain, cranium and intracranial organs
2.2 - Cranium
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
14 - Female reproductive organs
14.4 - Vagina/perineum
12 - Urinary system and male reproductive organs
12.4 - Urethra
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
15 - Skin and subcutaneous tissue
15.2 - Repair
4 - Eye and orbital contents
4.2 - Eyebrow and lid
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
14 - Female reproductive organs
14.4 - Vagina/perineum
5 - Ear, nose and throat
5.7 - Larynx and trachea
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
14 - Female reproductive organs
14.1 - Uterus/adnexa
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
12 - Urinary system and male reproductive organs
12.3 - Bladder
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
14 - Female reproductive organs
14.1 - Uterus/adnexa
4 - Eye and orbital contents
4.5 - Conjuctiva
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
16.10 - Knee
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
20 - Radiotherapy
20.0 - Radiotherapy
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
7 - Breast
7.3 - Reconstruction
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
22 - Gender Affirmation
14 - Female reproductive organs
14.1 - Uterus/adnexa
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
12 - Urinary system and male reproductive organs
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
9 - Vascular system
9.7 - Varicose veins
17 - Interventional radiology
17.11 - Liver
22 - Gender Affirmation
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
12 - Urinary system and male reproductive organs
12.4 - Urethra
5 - Ear, nose and throat
5.3 - Inner ear
4 - Eye and orbital contents
4.1 - Globe and orbit
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
12 - Urinary system and male reproductive organs
12.6 - Genitalia
22 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
20 - Radiotherapy
20.0 - Radiotherapy
4 - Eye and orbital contents
4.6 - Cornea
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
17 - Interventional radiology
17.3 - Angioplasty
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.8 - Other procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
4 - Eye and orbital contents
4.10 - Vitreous
2 - Brain, cranium and intracranial organs
2.1 - Brain
12 - Urinary system and male reproductive organs
12.6 - Genitalia
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
5 - Ear, nose and throat
5.6 - Throat
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
22 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
22 - Gender Affirmation
6 - Face, mouth, salivary and thyroid
6.4 - Palate
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
5 - Ear, nose and throat
5.7 - Larynx and trachea
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
22 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
22 - Gender Affirmation
22.0 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
2 - Brain, cranium and intracranial organs
2.5 - Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
22 - Gender Affirmation
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
9 - Vascular system
9.1 - Head and neck
22 - Gender Affirmation
5 - Ear, nose and throat
5.6 - Throat
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
17 - Interventional radiology
17.11 - Liver
4 - Eye and orbital contents
4.6 - Cornea
12 - Urinary system and male reproductive organs
12.3 - Bladder
22 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
22 - Gender Affirmation
17 - Interventional radiology
17.12 - Urinary
22 - Gender Affirmation
14 - Female reproductive organs
14.1 - Uterus/adnexa
22 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
11.9 - Abdominal wall
22 - Gender Affirmation
22.0 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
22 - Gender Affirmation
22.0 - Gender Affirmation
5 - Ear, nose and throat
5.5 - Nasal sinuses
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
12 - Urinary system and male reproductive organs
12.5 - Prostate
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.5 - Conjuctiva
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
20 - Radiotherapy
20.0 - Radiotherapy
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
13 - Pregnancy and confinement
13.0 - Pregnancy and confinement
9 - Vascular system
9.7 - Varicose veins
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
2 - Brain, cranium and intracranial organs
2.5 - Vessels
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
12 - Urinary system and male reproductive organs
12.3 - Bladder
20 - Radiotherapy
20.0 - Radiotherapy
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
8.9 - Heart – cardiology
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
17 - Interventional radiology
17.4 - Embolisation
4 - Eye and orbital contents
4.2 - Eyebrow and lid
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
17 - Interventional radiology
17.1 - Biopsy
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
17 - Interventional radiology
17.13 - Other
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
3.8 - Other procedures
4 - Eye and orbital contents
4.9 - Lens
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
2 - Brain, cranium and intracranial organs
2.1 - Brain
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
14 - Female reproductive organs
14.2 - Suspension
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
20 - Radiotherapy
20.0 - Radiotherapy
17 - Interventional radiology
17.4 - Embolisation
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
4 - Eye and orbital contents
4.4 - Muscles
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
8.8 - Heart – cardiac surgery
2 - Brain, cranium and intracranial organs
2.4 - Nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
17 - Interventional radiology
17.4 - Embolisation
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
17 - Interventional radiology
17.12 - Urinary
18 - Chemotherapy
18.0 - Chemotherapy
7 - Breast
7.3 - Reconstruction
17 - Interventional radiology
17.13 - Other
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.6 - Cornea
20 - Radiotherapy
20.0 - Radiotherapy
22 - Gender Affirmation
17 - Interventional radiology
17.13 - Other
12 - Urinary system and male reproductive organs
12.6 - Genitalia
20 - Radiotherapy
20.0 - Radiotherapy
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.9 - Hip, leg and pelvis
4 - Eye and orbital contents
4.9 - Lens
7 - Breast
7.3 - Reconstruction
22 - Gender Affirmation
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
22 - Gender Affirmation
22.0 - Gender Affirmation
9 - Vascular system
9.6 - Non-specific
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
17 - Interventional radiology
17.3 - Angioplasty
9 - Vascular system
9.6 - Non-specific
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.6 - Hand
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
4 - Eye and orbital contents
4.11 - Retina
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.5 - Prostate
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
7 - Breast
7.3 - Reconstruction
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
17 - Interventional radiology
17.4 - Embolisation
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
17 - Interventional radiology
17.4 - Embolisation
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
5 - Ear, nose and throat
5.1 - External ear
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
22 - Gender Affirmation
22.0 - Gender Affirmation
15 - Skin and subcutaneous tissue
22 - Gender Affirmation
22.0 - Gender Affirmation
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
5 - Ear, nose and throat
5.6 - Throat
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
12 - Urinary system and male reproductive organs
12.3 - Bladder
20 - Radiotherapy
20.0 - Radiotherapy
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
7.4 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
5 - Ear, nose and throat
5.5 - Nasal sinuses
5.7 - Larynx and trachea
6 - Face, mouth, salivary and thyroid
6.4 - Palate
4 - Eye and orbital contents
4.10 - Vitreous
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
20 - Radiotherapy
20.0 - Radiotherapy
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
7 - Breast
7.4 - Other
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.3 - Paraspinal injections
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
14 - Female reproductive organs
14.4 - Vagina/perineum
9 - Vascular system
9.6 - Non-specific
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
2 - Brain, cranium and intracranial organs
2.2 - Cranium
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
7 - Breast
7.3 - Reconstruction
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.3 - Paraspinal injections
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
9 - Vascular system
9.6 - Non-specific
20 - Radiotherapy
20.0 - Radiotherapy
14 - Female reproductive organs
14.4 - Vagina/perineum
20 - Radiotherapy
20.0 - Radiotherapy
14 - Female reproductive organs
14.4 - Vagina/perineum
12 - Urinary system and male reproductive organs
12.5 - Prostate
2 - Brain, cranium and intracranial organs
2.2 - Cranium
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
8 - Thorax and intra-thoracic organs
8.3 - Trachea
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
6 - Face, mouth, salivary and thyroid
6.2 - Lips
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
14 - Female reproductive organs
14.1 - Uterus/adnexa
9 - Vascular system
9.4 - Abdominal vessels
9.6 - Non-specific
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
4 - Eye and orbital contents
4.9 - Lens
5 - Ear, nose and throat
5.5 - Nasal sinuses
6 - Face, mouth, salivary and thyroid
6.2 - Lips
6.8 - Neck
4 - Eye and orbital contents
4.2 - Eyebrow and lid
14 - Female reproductive organs
14.4 - Vagina/perineum
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
9 - Vascular system
9.6 - Non-specific
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.1 - Oesophagus
11.6 - Rectum/anus
22 - Gender Affirmation
22.0 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
12 - Urinary system and male reproductive organs
12.3 - Bladder
20 - Radiotherapy
20.0 - Radiotherapy
12 - Urinary system and male reproductive organs
12.5 - Prostate
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
18 - Chemotherapy
18.0 - Chemotherapy
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
19 - Haematology (Hospital Use Only)
19.1 - Bone Marrow
22 - Gender Affirmation
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
22 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.6 - Cornea
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
15 - Skin and subcutaneous tissue
15.2 - Repair
2 - Brain, cranium and intracranial organs
2.3 - Meninges
22 - Gender Affirmation
22.0 - Gender Affirmation
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
9 - Vascular system
9.2 - Thoracic vessels
4 - Eye and orbital contents
4.11 - Retina
6 - Face, mouth, salivary and thyroid
6.2 - Lips
20 - Radiotherapy
20.0 - Radiotherapy
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
4 - Eye and orbital contents
4.2 - Eyebrow and lid
17 - Interventional radiology
17.3 - Angioplasty
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
5 - Ear, nose and throat
5.7 - Larynx and trachea
2 - Brain, cranium and intracranial organs
2.6 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
5 - Ear, nose and throat
5.1 - External ear
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.1 - Globe and orbit
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
12 - Urinary system and male reproductive organs
12.5 - Prostate
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
9 - Vascular system
9.5 - Ileo-femoral vessels
9.8 - Lymphatic system
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
4 - Eye and orbital contents
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.11 - Foot
14 - Female reproductive organs
14.1 - Uterus/adnexa
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.6 - Genitalia
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
22 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
22 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
15 - Skin and subcutaneous tissue
15.2 - Repair
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.2 - Spinal cord
3.8 - Other procedures
2 - Brain, cranium and intracranial organs
2.1 - Brain
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
4 - Eye and orbital contents
4.11 - Retina
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
12 - Urinary system and male reproductive organs
12.2 - Ureter
17 - Interventional radiology
17.7 - Head and neck
9 - Vascular system
9.4 - Abdominal vessels
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
2 - Brain, cranium and intracranial organs
2.4 - Nerves
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.2 - Spinal cord
15 - Skin and subcutaneous tissue
15.2 - Repair
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
2 - Brain, cranium and intracranial organs
2.6 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
22 - Gender Affirmation
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
9 - Vascular system
9.8 - Lymphatic system
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
4 - Eye and orbital contents
4.2 - Eyebrow and lid
20 - Radiotherapy
20.0 - Radiotherapy
2 - Brain, cranium and intracranial organs
2.1 - Brain
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
14 - Female reproductive organs
14.5 - Vulva/labia
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.2 - Eyebrow and lid
9 - Vascular system
9.7 - Varicose veins
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
22 - Gender Affirmation
22.0 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
15 - Skin and subcutaneous tissue
15.2 - Repair
5 - Ear, nose and throat
5.7 - Larynx and trachea
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
12 - Urinary system and male reproductive organs
12.4 - Urethra
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
12 - Urinary system and male reproductive organs
12.6 - Genitalia
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
4 - Eye and orbital contents
4.2 - Eyebrow and lid
4.3 - Lacrimal system
7 - Breast
7.3 - Reconstruction
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
12 - Urinary system and male reproductive organs
12.5 - Prostate
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
12 - Urinary system and male reproductive organs
12.5 - Prostate
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
14 - Female reproductive organs
14.2 - Suspension
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
14 - Female reproductive organs
14.4 - Vagina/perineum
9 - Vascular system
9.1 - Head and neck
12 - Urinary system and male reproductive organs
12.5 - Prostate
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
9 - Vascular system
9.4 - Abdominal vessels
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
22 - Gender Affirmation
14 - Female reproductive organs
14.4 - Vagina/perineum
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
13 - Pregnancy and confinement
13.0 - Pregnancy and confinement
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
2 - Brain, cranium and intracranial organs
2.2 - Cranium
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
6.9 - Thyroid and parathyroid glands
5 - Ear, nose and throat
5.5 - Nasal sinuses
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
2 - Brain, cranium and intracranial organs
2.4 - Nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
4 - Eye and orbital contents
4.4 - Muscles
4.11 - Retina
5 - Ear, nose and throat
5.7 - Larynx and trachea
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
5 - Ear, nose and throat
5.1 - External ear
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.5 - Nasal sinuses
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
9 - Vascular system
9.5 - Ileo-femoral vessels
5 - Ear, nose and throat
5.1 - External ear
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
9 - Vascular system
9.7 - Varicose veins
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
20 - Radiotherapy
20.0 - Radiotherapy
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
4 - Eye and orbital contents
4.2 - Eyebrow and lid
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
9 - Vascular system
9.8 - Lymphatic system
12 - Urinary system and male reproductive organs
12.5 - Prostate
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.4 - Small intestine
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
7 - Breast
7.3 - Reconstruction
5 - Ear, nose and throat
5.5 - Nasal sinuses
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
5 - Ear, nose and throat
5.7 - Larynx and trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
5 - Ear, nose and throat
5.7 - Larynx and trachea
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
2 - Brain, cranium and intracranial organs
2.1 - Brain
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.3 - Bladder
17 - Interventional radiology
17.13 - Other
7 - Breast
7.3 - Reconstruction
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
12 - Urinary system and male reproductive organs
12.3 - Bladder
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
12 - Urinary system and male reproductive organs
12.3 - Bladder
5 - Ear, nose and throat
5.1 - External ear
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
11.7 - Other organs (mainly digestive)
22 - Gender Affirmation
22.0 - Gender Affirmation
4 - Eye and orbital contents
4.1 - Globe and orbit
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
17 - Interventional radiology
17.2 - Drainage
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
5 - Ear, nose and throat
5.7 - Larynx and trachea
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.9 - Heart – cardiology
8.9 - Heart – cardiology
14 - Female reproductive organs
14.4 - Vagina/perineum
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
2 - Brain, cranium and intracranial organs
2.1 - Brain
8 - Thorax and intra-thoracic organs
8.3 - Trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
12 - Urinary system and male reproductive organs
12.2 - Ureter
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
22 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
10 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
14 - Female reproductive organs
14.4 - Vagina/perineum
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
17 - Interventional radiology
17.5 - Thrombolysis
6 - Face, mouth, salivary and thyroid
6.2 - Lips
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
22 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.10 - Knee
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
22 - Gender Affirmation
22.0 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
22 - Gender Affirmation
22.0 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
9 - Vascular system
9.7 - Varicose veins
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.11 - Other
9 - Vascular system
9.5 - Ileo-femoral vessels
17 - Interventional radiology
17.13 - Other
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
12 - Urinary system and male reproductive organs
12.2 - Ureter
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
14 - Female reproductive organs
14.1 - Uterus/adnexa
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
5 - Ear, nose and throat
5.1 - External ear
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
8.8 - Heart – cardiac surgery
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
22 - Gender Affirmation
12 - Urinary system and male reproductive organs
12.5 - Prostate
20 - Radiotherapy
20.0 - Radiotherapy
7 - Breast
7.3 - Reconstruction
2 - Brain, cranium and intracranial organs
2.3 - Meninges
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
9 - Vascular system
9.7 - Varicose veins
9.8 - Lymphatic system
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
5 - Ear, nose and throat
5.5 - Nasal sinuses
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
16.12 - External fixation/traction
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.10 - Great Vessels
6 - Face, mouth, salivary and thyroid
6.8 - Neck
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
5 - Ear, nose and throat
5.3 - Inner ear
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
9 - Vascular system
9.2 - Thoracic vessels
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
6 - Face, mouth, salivary and thyroid
6.4 - Palate
12 - Urinary system and male reproductive organs
12.2 - Ureter
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.7 - Larynx and trachea
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
5 - Ear, nose and throat
5.1 - External ear
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
6 - Face, mouth, salivary and thyroid
6.4 - Palate
20 - Radiotherapy
20.0 - Radiotherapy
5 - Ear, nose and throat
5.1 - External ear
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
7 - Breast
7.3 - Reconstruction
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
12 - Urinary system and male reproductive organs
12.5 - Prostate
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
22 - Gender Affirmation
9 - Vascular system
9.7 - Varicose veins
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
4 - Eye and orbital contents
4.9 - Lens
7 - Breast
7.3 - Reconstruction
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
12 - Urinary system and male reproductive organs
12.2 - Ureter
12.3 - Bladder
4 - Eye and orbital contents
4.7 - Sclera
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
14 - Female reproductive organs
14.3 - Cervix uteri
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
7 - Breast
7.1 - Excision/biopsy codes
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.5 - Prostate
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
11.6 - Rectum/anus
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.3 - Bladder
9 - Vascular system
9.7 - Varicose veins
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
20 - Radiotherapy
20.0 - Radiotherapy
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
4 - Eye and orbital contents
4.3 - Lacrimal system
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
2 - Brain, cranium and intracranial organs
2.2 - Cranium
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
22 - Gender Affirmation
17 - Interventional radiology
17.4 - Embolisation
22 - Gender Affirmation
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
5 - Ear, nose and throat
5.3 - Inner ear
5.7 - Larynx and trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
2 - Brain, cranium and intracranial organs
2.3 - Meninges
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
12 - Urinary system and male reproductive organs
12.6 - Genitalia
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
9 - Vascular system
9.8 - Lymphatic system
2 - Brain, cranium and intracranial organs
2.5 - Vessels
17 - Interventional radiology
17.8 - Spine
7 - Breast
7.1 - Excision/biopsy codes
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
22 - Gender Affirmation
22.0 - Gender Affirmation
7 - Breast
7.3 - Reconstruction
7.4 - Other
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
22 - Gender Affirmation
20 - Radiotherapy
20.0 - Radiotherapy
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
14 - Female reproductive organs
14.2 - Suspension
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
16.11 - Foot
20 - Radiotherapy
20.0 - Radiotherapy
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
9 - Vascular system
9.3 - Renal vessels
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
9 - Vascular system
9.3 - Renal vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
17 - Interventional radiology
17.8 - Spine
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
14 - Female reproductive organs
14.4 - Vagina/perineum
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
22 - Gender Affirmation
22.0 - Gender Affirmation
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.6 - Throat
7 - Breast
7.4 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
5 - Ear, nose and throat
5.6 - Throat
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.3 - Bladder
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
5 - Ear, nose and throat
5.7 - Larynx and trachea
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
7 - Breast
7.1 - Excision/biopsy codes
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
9 - Vascular system
9.3 - Renal vessels
9.6 - Non-specific
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
9 - Vascular system
9.1 - Head and neck
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
14 - Female reproductive organs
14.4 - Vagina/perineum
12 - Urinary system and male reproductive organs
12.4 - Urethra
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
3.9 - Neurophysiological procedures
22 - Gender Affirmation
22.0 - Gender Affirmation
6 - Face, mouth, salivary and thyroid
6.8 - Neck
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
14 - Female reproductive organs
14.1 - Uterus/adnexa
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
20 - Radiotherapy
20.0 - Radiotherapy
14 - Female reproductive organs
14.3 - Cervix uteri
4 - Eye and orbital contents
4.6 - Cornea
4.11 - Retina
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
20 - Radiotherapy
20.0 - Radiotherapy
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.5 - Prostate
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
22 - Gender Affirmation
22.0 - Gender Affirmation
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
5 - Ear, nose and throat
5.6 - Throat
7 - Breast
7.4 - Other
2 - Brain, cranium and intracranial organs
2.6 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
2 - Brain, cranium and intracranial organs
2.4 - Nerves
4 - Eye and orbital contents
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
4 - Eye and orbital contents
4.2 - Eyebrow and lid
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
7 - Breast
7.3 - Reconstruction
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
12 - Urinary system and male reproductive organs
12.6 - Genitalia
4 - Eye and orbital contents
4.5 - Conjuctiva
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
2 - Brain, cranium and intracranial organs
2.1 - Brain
9 - Vascular system
9.5 - Ileo-femoral vessels
2 - Brain, cranium and intracranial organs
2.2 - Cranium
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
22 - Gender Affirmation
22.0 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.7 - Shoulder
16.9 - Hip, leg and pelvis
17 - Interventional radiology
17.8 - Spine
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
17 - Interventional radiology
17.11 - Liver
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.4 - Muscles
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
5 - Ear, nose and throat
5.5 - Nasal sinuses
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
7 - Breast
7.1 - Excision/biopsy codes
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
14 - Female reproductive organs
14.3 - Cervix uteri
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.5 - Nasal sinuses
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.4 - Small intestine
4 - Eye and orbital contents
4.3 - Lacrimal system
4.8 - Iris and anterior chamber
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
14 - Female reproductive organs
14.3 - Cervix uteri
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
4 - Eye and orbital contents
4.1 - Globe and orbit
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
17 - Interventional radiology
17.1 - Biopsy
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
8.10 - Great Vessels
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
4 - Eye and orbital contents
4.11 - Retina
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.9 - Abdominal wall
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
9 - Vascular system
9.6 - Non-specific
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
12 - Urinary system and male reproductive organs
12.5 - Prostate
20 - Radiotherapy
20.0 - Radiotherapy
17 - Interventional radiology
17.4 - Embolisation
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.9 - Hip, leg and pelvis
14 - Female reproductive organs
14.4 - Vagina/perineum
22 - Gender Affirmation
22.0 - Gender Affirmation
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
22 - Gender Affirmation
22.0 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
12 - Urinary system and male reproductive organs
12.2 - Ureter
7 - Breast
7.1 - Excision/biopsy codes
5 - Ear, nose and throat
5.7 - Larynx and trachea
2 - Brain, cranium and intracranial organs
2.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.2 - Eyebrow and lid
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.6 - Throat
2 - Brain, cranium and intracranial organs
2.2 - Cranium
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
2 - Brain, cranium and intracranial organs
2.1 - Brain
4 - Eye and orbital contents
4.4 - Muscles
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
5 - Ear, nose and throat
5.6 - Throat
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.9 - Neurophysiological procedures
12 - Urinary system and male reproductive organs
12.6 - Genitalia
4 - Eye and orbital contents
4.5 - Conjuctiva
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.2 - Lips
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
2 - Brain, cranium and intracranial organs
2.1 - Brain
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
9 - Vascular system
9.3 - Renal vessels
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
4 - Eye and orbital contents
4.6 - Cornea
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
14 - Female reproductive organs
14.2 - Suspension
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
22 - Gender Affirmation
22.0 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
4 - Eye and orbital contents
4.3 - Lacrimal system
17 - Interventional radiology
17.12 - Urinary
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
12 - Urinary system and male reproductive organs
12.3 - Bladder
14 - Female reproductive organs
14.1 - Uterus/adnexa
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
9 - Vascular system
9.6 - Non-specific
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
12 - Urinary system and male reproductive organs
12.5 - Prostate
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
4 - Eye and orbital contents
4.1 - Globe and orbit
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
15 - Skin and subcutaneous tissue
15.2 - Repair
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.1 - Globe and orbit
4.3 - Lacrimal system
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
9 - Vascular system
9.6 - Non-specific
17 - Interventional radiology
17.4 - Embolisation
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
9 - Vascular system
9.5 - Ileo-femoral vessels
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.11 - Foot
2 - Brain, cranium and intracranial organs
2.1 - Brain
4 - Eye and orbital contents
4.1 - Globe and orbit
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
9 - Vascular system
9.6 - Non-specific
5 - Ear, nose and throat
5.1 - External ear
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
17 - Interventional radiology
17.4 - Embolisation
4 - Eye and orbital contents
4.11 - Retina
12 - Urinary system and male reproductive organs
12.3 - Bladder
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
5 - Ear, nose and throat
5.1 - External ear
5.5 - Nasal sinuses
4 - Eye and orbital contents
4.1 - Globe and orbit
7 - Breast
7.3 - Reconstruction
17 - Interventional radiology
17.13 - Other
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
3.8 - Other procedures
12 - Urinary system and male reproductive organs
12.6 - Genitalia
9 - Vascular system
9.6 - Non-specific
4 - Eye and orbital contents
4.1 - Globe and orbit
4.4 - Muscles
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
16.12 - External fixation/traction
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.8 - Elbow
5 - Ear, nose and throat
5.3 - Inner ear
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
9 - Vascular system
9.6 - Non-specific
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
14 - Female reproductive organs
14.5 - Vulva/labia
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
5 - Ear, nose and throat
5.3 - Inner ear
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
5 - Ear, nose and throat
5.5 - Nasal sinuses
4 - Eye and orbital contents
4.6 - Cornea
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
8.8 - Heart – cardiac surgery
2 - Brain, cranium and intracranial organs
2.4 - Nerves
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
14 - Female reproductive organs
14.3 - Cervix uteri
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
2 - Brain, cranium and intracranial organs
2.4 - Nerves
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.11 - Foot
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
9 - Vascular system
9.8 - Lymphatic system
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
4 - Eye and orbital contents
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
17 - Interventional radiology
17.1 - Biopsy
8 - Thorax and intra-thoracic organs
8.3 - Trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
2 - Brain, cranium and intracranial organs
2.1 - Brain
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
15 - Skin and subcutaneous tissue
15.2 - Repair
17 - Interventional radiology
17.3 - Angioplasty
12 - Urinary system and male reproductive organs
12.3 - Bladder
12.6 - Genitalia
4 - Eye and orbital contents
4.6 - Cornea
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.7 - Other organs (mainly digestive)
11.9 - Abdominal wall
17 - Interventional radiology
17.10 - Gastrointestinal
6 - Face, mouth, salivary and thyroid
6.8 - Neck
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
7 - Breast
7.1 - Excision/biopsy codes
12 - Urinary system and male reproductive organs
12.5 - Prostate
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
9 - Vascular system
9.6 - Non-specific
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
12 - Urinary system and male reproductive organs
12.3 - Bladder
7 - Breast
7.3 - Reconstruction
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
14 - Female reproductive organs
14.5 - Vulva/labia
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
19 - Haematology (Hospital Use Only)
19.1 - Bone Marrow
22 - Gender Affirmation
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
12 - Urinary system and male reproductive organs
12.4 - Urethra
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
22 - Gender Affirmation
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.6 - Hand
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
7 - Breast
7.3 - Reconstruction
4 - Eye and orbital contents
4.9 - Lens
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.7 - Larynx and trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
4 - Eye and orbital contents
4.9 - Lens
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
9 - Vascular system
9.6 - Non-specific
20 - Radiotherapy
20.0 - Radiotherapy
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
14 - Female reproductive organs
14.1 - Uterus/adnexa
5 - Ear, nose and throat
5.6 - Throat
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
20 - Radiotherapy
20.0 - Radiotherapy
12 - Urinary system and male reproductive organs
12.4 - Urethra
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
17 - Interventional radiology
17.13 - Other
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
2 - Brain, cranium and intracranial organs
2.1 - Brain
2.2 - Cranium
9 - Vascular system
9.2 - Thoracic vessels
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.1 - External ear
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
4 - Eye and orbital contents
4.11 - Retina
12 - Urinary system and male reproductive organs
12.6 - Genitalia
4 - Eye and orbital contents
4.9 - Lens
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.2 - Eyebrow and lid
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
17 - Interventional radiology
17.13 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.6 - Hand
16.9 - Hip, leg and pelvis
16.11 - Foot
12 - Urinary system and male reproductive organs
12.2 - Ureter
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
12 - Urinary system and male reproductive organs
12.3 - Bladder
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
15 - Skin and subcutaneous tissue
15.2 - Repair
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.5 - Nasal sinuses
5.7 - Larynx and trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
22 - Gender Affirmation
14 - Female reproductive organs
14.1 - Uterus/adnexa
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.10 - Knee
22 - Gender Affirmation
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
20 - Radiotherapy
20.0 - Radiotherapy
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
20 - Radiotherapy
20.0 - Radiotherapy
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
7 - Breast
7.1 - Excision/biopsy codes
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
17 - Interventional radiology
17.13 - Other
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
14 - Female reproductive organs
14.1 - Uterus/adnexa
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
22 - Gender Affirmation
22.0 - Gender Affirmation
5 - Ear, nose and throat
5.1 - External ear
4 - Eye and orbital contents
4.9 - Lens
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
9 - Vascular system
9.4 - Abdominal vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.9 - Hip, leg and pelvis
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
17 - Interventional radiology
17.4 - Embolisation
12 - Urinary system and male reproductive organs
12.3 - Bladder
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
3 - Spine, spinal cord and peripheral nerves
3.4 - Nerve roots
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
4 - Eye and orbital contents
4.3 - Lacrimal system
12 - Urinary system and male reproductive organs
12.3 - Bladder
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
7 - Breast
7.4 - Other
5 - Ear, nose and throat
5.6 - Throat
9 - Vascular system
9.8 - Lymphatic system
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.11 - Foot
9 - Vascular system
9.6 - Non-specific
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
4 - Eye and orbital contents
4.6 - Cornea
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
17 - Interventional radiology
17.3 - Angioplasty
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
17 - Interventional radiology
17.2 - Drainage
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
5 - Ear, nose and throat
5.5 - Nasal sinuses
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.13 - Amputation
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.3 - Bladder
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.9 - Hip, leg and pelvis
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
16.10 - Knee
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.5 - Prostate
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
2 - Brain, cranium and intracranial organs
2.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
3.7 - Other nerve blocks
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
2 - Brain, cranium and intracranial organs
2.1 - Brain
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
17 - Interventional radiology
17.1 - Biopsy
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
14 - Female reproductive organs
14.4 - Vagina/perineum
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
19 - Haematology (Hospital Use Only)
19.2 - Stem Cell
5 - Ear, nose and throat
5.3 - Inner ear
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
19 - Haematology (Hospital Use Only)
19.2 - Stem Cell
22 - Gender Affirmation
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
14 - Female reproductive organs
14.2 - Suspension
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
22 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.8 - Elbow
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
7 - Breast
7.4 - Other
17 - Interventional radiology
17.12 - Urinary
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
9 - Vascular system
9.6 - Non-specific
14 - Female reproductive organs
14.1 - Uterus/adnexa
9 - Vascular system
9.7 - Varicose veins
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
7 - Breast
7.1 - Excision/biopsy codes
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
2 - Brain, cranium and intracranial organs
2.1 - Brain
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
11.9 - Abdominal wall
22 - Gender Affirmation
22.0 - Gender Affirmation
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
12 - Urinary system and male reproductive organs
12.6 - Genitalia
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
9 - Vascular system
9.4 - Abdominal vessels
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.8 - Major vessels
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
17 - Interventional radiology
17.13 - Other
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
14 - Female reproductive organs
14.1 - Uterus/adnexa
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
7 - Breast
7.3 - Reconstruction
14 - Female reproductive organs
14.2 - Suspension
5 - Ear, nose and throat
5.5 - Nasal sinuses
15 - Skin and subcutaneous tissue
15.2 - Repair
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
6.9 - Thyroid and parathyroid glands
14 - Female reproductive organs
14.4 - Vagina/perineum
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
2 - Brain, cranium and intracranial organs
2.1 - Brain
12 - Urinary system and male reproductive organs
12.6 - Genitalia
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
9 - Vascular system
9.6 - Non-specific
4 - Eye and orbital contents
4.2 - Eyebrow and lid
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
9 - Vascular system
9.6 - Non-specific
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
4 - Eye and orbital contents
4.2 - Eyebrow and lid
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
8.2 - Chest wall
12 - Urinary system and male reproductive organs
12.2 - Ureter
12.5 - Prostate
5 - Ear, nose and throat
5.7 - Larynx and trachea
7 - Breast
7.4 - Other
12 - Urinary system and male reproductive organs
12.6 - Genitalia
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
17 - Interventional radiology
17.4 - Embolisation
11 - Abdomen (excluding urinary and reproductive organs)
11.8 - Major vessels
14 - Female reproductive organs
14.5 - Vulva/labia
2 - Brain, cranium and intracranial organs
2.2 - Cranium
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
18 - Chemotherapy
18.0 - Chemotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
5 - Ear, nose and throat
5.5 - Nasal sinuses
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.8 - Major vessels
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
5.7 - Larynx and trachea
14 - Female reproductive organs
14.1 - Uterus/adnexa
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
2 - Brain, cranium and intracranial organs
2.2 - Cranium
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.4 - Consultations and Physicians’ fees
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
19 - Haematology (Hospital Use Only)
19.1 - Bone Marrow
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
7 - Breast
7.3 - Reconstruction
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
22 - Gender Affirmation
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
22 - Gender Affirmation
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
20 - Radiotherapy
20.0 - Radiotherapy
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
13 - Pregnancy and confinement
13.0 - Pregnancy and confinement
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
11.7 - Other organs (mainly digestive)
11.10 - Peritoneum
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
7 - Breast
7.3 - Reconstruction
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.3 - Bladder
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
22 - Gender Affirmation
22.0 - Gender Affirmation
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
15 - Skin and subcutaneous tissue
15.2 - Repair
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.10 - Great Vessels
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
14 - Female reproductive organs
14.1 - Uterus/adnexa
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.7 - Other organs (mainly digestive)
17 - Interventional radiology
17.2 - Drainage
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
7 - Breast
7.3 - Reconstruction
15 - Skin and subcutaneous tissue
15.2 - Repair
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.9 - Hip, leg and pelvis
14 - Female reproductive organs
14.1 - Uterus/adnexa
6 - Face, mouth, salivary and thyroid
6.2 - Lips
7 - Breast
7.3 - Reconstruction
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.1 - External ear
5.7 - Larynx and trachea
14 - Female reproductive organs
14.1 - Uterus/adnexa
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
16.11 - Foot
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
5 - Ear, nose and throat
5.6 - Throat
Copyright
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means (including photocopying and recording) without the written permission of AXA Health limited. The written permission of AXA Health limited must also be obtained before any part of this publication is stored in a retrieval system of any nature. Applications for written permission to reproduce, transmit or store in a retrieval system any part of this publication should be addressed to Group General Counsel, 5 Old Broad Street, London EC2N 1AD.
Warning: the doing of an unauthorised act in relation to copyright work may result in both a civil claim or damages and criminal prosecution.
This work is based on the CCSD Schedule of Procedures © The Clinical Coding and Schedule Development Group.
Material contained in the Office of Population Censuses and Surveys Classification of Operations and Surgical Procedures Consolidated Fourth Revision, is © Crown Copyright 1990 and has been reproduced by kind permission of the Controller of Her Majesty’s Stationery Office and the NHSIA.
Billing Principles: Introduction
These Billing Principles will give you clarity in your work with us and support for your patients' care.
In these Principles we tell you what services and treatment we will and will not pay for. The information will guide you on when you need to contact us, helps in paying your invoices quickly, and ensures our work together runs smoothly.
Following these Principles also means giving us the information we need, at the right time. This helps ensure we can best support your patient's care and that commercial discussions don't get in the way of treatment.
We do expect you to adhere to these Principles, which support your recognition and form part of your contract. Failure to adhere to these principles may affect your recognition with us.
Important Points
- We will pay eligible fees in full when you charge up to the level shown within the Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/ for treatment you have provided. We will not pay for you to supervise services provided by others. Publication of a code in the Schedule does not guarantee eligibility for every member therefore you should ensure that all treatment has been pre-authorised in advance of any treatment taking place.
- Please do not bill for any service or treatment that is not listed in the Schedule of Procedures and Fees, outlined in these Billing Principles or outlined in your contract, without first seeking approval from AXA Health.
- In line with the good practice guidelines of your regulatory authority, any medical records or information you send us should be complete, accurate, clear and signed by the treating provider. They should include details of procedures, treatments or consultations as appropriate and include the patient's name, relevant dates and treatment start and end times. If in any doubt, please send us typed copies of medical records, with copies of the originals.
- Our memberships are designed to cover the costs of the short-term treatment of acute medical conditions. Generally they do not cover treatments and procedures that are considered primarily cosmetic in nature. There are some exceptions, for example, following treatment for cancer. If in doubt, please contact us in advance by submitting a copy of your clinic letter using our specialist fees enquiry form https://provider.axahealth.co.uk/individual/individual-provider-support/ we will then consider your request.
- As the treating provider, we hold you responsible for ensuring the information you provide, such as coding or medical notes, is accurate. This is important as we use this information to assess eligibility and to settle claims.
- We need time to consider pre-operative requests which may affect your fees or the way you carry out a procedure. Please send us the relevant information at least five working days before the scheduled treatment.
- We expect you to follow the ethical guidance provided by your regulatory body. An example of such guidance from the General Medical Council (GMC) can be found here: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/duties-of-a-doctor
- Please do not consider the provisions of any sections of these Billing Principles in isolation. Each section should be considered in relation to the others.
1: Pre-Treatment And Pre-Authorisation Provisions
1.1 - Consultations
We define a consultation, whether face-to-face or remote, as a meeting between patient and provider to:
- evaluate the nature and progress of an active condition.
- establish a diagnosis, prognosis and treatment plan.
An email exchange with a patient is not classed as a remote consultation. Remote consultation charges should only be made where a face-to-face consultation would previously have occurred. Short consultations, for example to inform patients about results or for largely administrative matters, should not be charged for.
We set the consultation fee,
- to include all charges relating to that consultation, whether face-to-face or remote (for example, room fees or IT costs).
- to accommodate all consultations, including those which may be longer or be more complex than the norm. We expect you to see each patient for the appropriate time to treat their individual condition. We do not expect to be invoiced for additional time or double sessions when treatment has overrun the scheduled time.
We expect to be billed for only one consultation for each patient on any given day. You may perform certain unplanned minor operations during face-to-face consultations. Please bill for these using the codes listed in our Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/
We will pay for in-patient consultations if you:
- are the physician in charge of the patient's care,
- have visited them in hospital and
- are not providing routine post-operative care.
These will be paid at the daily attendance fee rate. We would not expect you to bill for a consultation if you:
- are on call, or
- have performed a procedure on or provided anaesthesia to the patient in question within the past 10 days, or
- are performing a planned procedure for that patient on the day of the consultation.
For further information regarding remote consultations please refer to the Remote consulting provisions on our provider information centre.
1.2 - Tests, Pathology And Diagnostic Radiology
You should only request diagnostic tests or pathology tests when you have reasonable suspicion of a medical condition. This should be in line with national guidelines and evidence-based practice, and where the tests are required to direct and manage a patient's treatment plan. Screening tests are generally excluded from coverage.
Please ensure patients are directed to a facility in our network for diagnostic tests (diagnostic tests are investigations, such as x-rays or blood tests, to find or to help to find the cause of a patients' symptoms. This does not include procedures).
We will not pay you separately for diagnostic tests at facilities in our network, or for reporting on the results of these diagnostics. We pay the hospital, clinic or facility directly for these services. If required, you should negotiate appropriate payment for your services directly with the facility. If the test you need to perform is not available at a recognised facility, please contact the Specialist Fees and Contracting Team here .
For any specimens taken in your consulting rooms on behalf of a recognised pathology facility, we would expect the invoices to come from the facility directly.
We reserve the right to refuse or recover money for any charges which are outside your agreed contract.
You may bill for therapeutic interventional radiology following our Schedule of Procedures and Fees Schedule of Procedures and Fees
1.3 - Information You Should Provide Before And After A Consultation
We expect you to comply with the Private Healthcare Market Investigation Order 2014, published by the Competition and Markets Authority (CMA). Before confirming an outpatient consultation appointment, you should give your patient the following information:
- the estimated cost of the consultation
- details of any financial interests you may have in the facility or its equipment
- a list of all insurers who recognise you
- a statement that insured patients should check with their insurers the cover they have
- a reason for further tests or treatment
- an estimate of the cumulative cost of the treatment pathway which has been recommended. This should include:
- all fees you charge separately from hospital fees
- contact details for any other consultants whose fees are not included in the quote
- a statement of services which have not been included in the estimate, such as those resulting from unforeseeable complications. Where alternative treatments are available but the appropriate treatment can only be decided during surgery, the estimate should set out the relevant options and associated fees.
- all fees you charge separately from hospital fees
Please also provide this information to the Private Healthcare Information Network (PHIN) www.phin.org.uk which provides patients with information to help them make their private healthcare choices.
After the consultation, you should provide your patient with all relevant CCSD coding for any proposed treatment so they may gain pre-authorisation from our Personal Advisers. If a patient doesn?t have the correct code to hand this may delay pre-authorisation.
1.4 - Treatment At A Facility Outside Our Network
The majority of our members have chosen a policy requiring them to receive treatment at one of our network facilities.
We pay all charges for eligible treatment at any hospital listed as a network facility in line with our agreements. In normal circumstances, we pay only a small daily benefit for treatment at a facility that is outside of our network and is not listed in our directory.
In exceptional circumstances, if a patient needs facilities or treatments which are not available at one of our network facilities, we may pay the charges.
You must agree this specific exemption with us before treatment or, in an emergency, as soon as possible after admission. Where we have agreed, we will pay all charges for eligible treatment at the relevant facility which is best placed to provide the necessary care.
To request an exemption, please complete the Hospital Exemption Request form on our Provider website https://www.axahealth.co.uk/network-exemption
The Network Development team will review your clinical reasons and let you know if we will accept treatment outside our network.
2: Treatment Provisions
2.1 - Coding
Please provide our members with all relevant CCSD coding in advance of their treatment so that this can be added to their claim. Without this information being provided upfront there may be delays in pre-authorisation being given. Pre-authorisation for any proposed treatment is needed in advance of the treatment taking place.
Your patients need to confirm they?re eligible for any proposed treatment plan by calling our Personal Advisory Team. We give our members this telephone number on their policy documents. If you need assistance with identifying the appropriate CCSD code then you can contact our Specialist Fees Team using this link https://provider.axahealth.co.uk/individual/individual-provider-support/
We work with the Clinical Coding and Schedule Development (CCSD) group to help create industry standard procedure codes. We publish any codes we introduce in the "Important information" section of our Schedule of Procedures and Fees. Please use these codes when billing us for treatment. They should be reasonable and within their intended purpose, as defined by the CCSD: https://www.ccsd.org.uk/
Procedure narratives and codes are protected by copyright and may not be altered or used in any way other than as published in the Schedule of Procedures and Fees.
If you believe there is no appropriate code for the treatment you wish to carry out or that the narrative does not reflect what you are doing, please contact the CCSD directly and request a new code. We review requests and possible changes with them regularly.
2.2 - Our Fees
We list the majority of procedures we pay for in our Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/
We will pay eligible fees in full when you charge up to the level shown within the Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/ for treatment you have provided. We will not pay for you to supervise services provided by others.
Your AXA provider code is for your personal use and should only be used for services that you have provided yourself. It should not be used for billing on behalf of others.
Our fees include all component parts, for example:
- pre-operative assessment
- the procedure itself, including local anaesthetic and/or intravenous (IV) sedation by the main operator
- all routine aftercare, including any consultations within 10 days of the procedure.
Please see Section 2.3 of these Principles for guidance on submitting an exception to this principle. We pay the hospital, facility or clinic directly for the in-patient services listed below. We do not pay you separately for these services:
- consumables, including drug costs.
- equipment charges.
- in-patient therapies.
If required, you should negotiate appropriate payment for your services with the facility.
2.3 - Our Fees: Exceptions
Please do not bill for any service or treatment not listed in the Schedule of Procedures and Fees, outlined in these Billing Principles or outlined in your contract, without first seeking approval from AXA Health. If you believe an additional fee is appropriate, for example where you have to see a patient within 10 days of their surgical procedure because the wound has reopened, please:
- tell us what fees you would like us to reconsider and why
- submit a copy of your clinic letter using our specialist fees enquiry form https://provider.axahealth.co.uk/individual/individual-provider-support/. We will then consider your request.
2.4 - Unsure What Code To Use For Surgery?
We may still cover procedures which are not listed by code in our Schedule of Procedures and Fees. We'll need additional information from you to help us consider your proposed treatment. If you can't find the code you need, please:
- give us a detailed analysis of what you're planning
- include the nearest appropriate code from our Schedule of Procedures and Fees and/or the CCSD website and
- submit a copy of your clinic letter using our specialist fees enquiry form https://provider.axahealth.co.uk/individual/individual-provider-support/
- make sure we have this information at least five working days before the procedure is due to take place.
We'll use this information to help find the correct code and we'll tell you the corresponding fee. When there is no appropriate procedure code, we will allocate the nearest code and may also review the fee independently, considering any additional complexities.
Once you have the right code, please share this with your patient so they can authorise their treatment. This will also help avoid any doubt when you invoice us.
2.5 - Unbundling
We take a common-sense approach to unbundling and will list the most frequently occurring procedures together. The list is not exhaustive, but we do not expect procedures to be broken down into their component steps.
Here are some examples of unbundling which show what we would consider unreasonable combinations or billing:
- charging for two procedures where one is part and parcel of the other or is so frequently performed that it is in effect part and parcel, for example suturing to close an operation wound
- charging for in-patient care or intensive treatment unit (ITU) care routinely considered part of the procedure, for example with a complex procedure such as a Whipples procedure
- charging for pre-operative or post-operative assessment or analgesia, including local anaesthetic or IV sedation by the specialist performing the procedure
- using procedure combinations whose primary purpose is to increase reimbursement. An example of this would be charging for wound infiltration with local anaesthesia or a Whipples procedure with a gallbladder removal code, as these elements are integral to the operation
- charging for an anaesthetic when an anaesthetist has provided anaesthetic services
- charging for a multidisciplinary team meeting
- consultations during a course of chemotherapy.
In most cases, we will outline which procedures we don't expect to see billed together on our Schedule of Procedures and Fees and publish these on our "Important changes" document on our website.
2.6 - Sole Procedures
A code has "sole procedure" in the narrative when it is usually performed by itself. Otherwise it is part and parcel of another procedure in the same area of the body. You should normally bill sole procedures in isolation, but there may be times that it is appropriate to bill a sole procedure code alongside another code. Please tell us about these exceptions by following the guidance below.
2.7 - Unbundling/Sole Procedures: Exceptions
Our unbundling or sole procedure rules may not apply if you perform procedures on a separate area of the body in a single session. If this applies in a specific case please:
- complete the specialist fees enquiry form on our Provider website https://provider.axahealth.co.uk/individual/individual-provider-support/, selecting "query about our billing principles", at least five working days before the procedure
- supply the relevant codes and areas of the body to support your request.
We'll tell you whether you can bill separately for these codes. If you submit an invoice without contacting us we will not pay all the separate charges or we may recoup money paid by mistake.
2.8 - Provider Code
Your Provider Code is your unique identifying code. Your Provider Code should be used solely to bill for treatment that you have carried out yourself for a member. You must not use your Provider Code to invoice for any treatment or services provided by anyone else. The only exception is where AXA Health has approved the appointment of a secondary specialist who has not been recognised by AXA Health to provide additional support in the treatment of a member by you (please see the 'Multiple Specialist Requests' section below).
3: Bespoke Requests
3.1 - Fee Uplifts and Multiple Specialist Requests
On occasion you may need to submit more than one code for surgery. When this happens we will pay the full amount for the procedure with the highest complexity and 50% of the fee for the second procedure.
We appreciate that we can't address every medical situation or surgical complication in setting fees. If you are planning a complex series of procedures which are not covered in the principle outlined in the paragraph above, we may consider a bespoke request.
This may include pre-operative or post-operative uplift requests and multiple specialist requests.
We define these here:
Pre-Operative Uplift Request
Where you anticipate a procedure will be more complex than expected, for a specific clinical reason, we will estimate the fee. We will need:
- an explanation of why an enhanced fee is appropriate
- the estimated time in theatre
- an indication of what you are likely to charge
- a full description of the procedure being performed and
- associated procedure codes.
Please note we will periodically audit the pre-operative requests we receive, and may request operation notes and anaesthetic charts post-operatively.
Post-Operative Uplift Request
We understand that complications can arise during surgery and we will consider paying an enhanced fee if this occurs. Please send us any information you think will help us decide whether an increased fee is appropriate. As a minimum we will need:
- a copy of the original operation notes (please also submit typed notes if handwritten notes are unclear)
- anaesthetic charts
- an indication of the fee requested.
Multiple Specialist Requests
We will only consider requests for additional specialists who are either: (i) recognised by AXA Health for benefit purposes in connection with the provision of treatment to members; or (ii) if they are not recognised by AXA Health, specialists or practitioners who are non-consultant grade practitioners working under the supervision of a specialist recognised by AXA Health and who you have ensured has and maintains medical malpractice insurance to the level required by the relevant Medical Regulations in connection with the treatment. Ultimately the lead surgeon has responsibility for the patient.
When agreeing treatment we will provide an estimate of fees paid for all specialists in connection with the treatment. If, after treatment, you would like us to adjust our estimate, please send us your operation notes and anaesthetic charts, so we can understand:
- your role and each additional specialist?s role in the procedure
- the time spent in theatre and
- the complexities faced.
We will then confirm the fee we will pay you for the treatment. We will not pay you for the fees, costs or expenses of any additional specialist where they are recognised by AXA Health. Additional specialists who are recognised by AXA Health should bill us separately under their own Provider Code. If you appoint an additional specialist who is not recognised by AXA Health, we will pay you directly for all fees in connection with the treatment of a member and it is your responsibility to direct the relevant fees to each additional specialist.
We will not pay you for the fees, costs or expenses of any additional specialist where you have not submitted a request to us for approval of the additional specialist.
Please submit your bespoke request using the specialist fees enquiry form on our Provider website https://provider.axahealth.co.uk/individual/individual-provider-support/
We review all requests individually using the evidence you provide.
We want to make sure your patients can confidently book treatment without worrying about what we will pay. To support with this, please allow at least five working days' notice for any pre-operative requests, including coding queries and requests for multiple specialists. We need this time to review the information you send us and make a decision.
Otherwise, we'll review your request post-operatively, at your own risk. Please note we do not pay for surgical assistants or for you to supervise services provided by others.
Ethical Guidance For Bespoke Requests
We expect you to follow the ethical guidance provided by your regulatory body. An example of such guidance from the GMC can be found here: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/duties-of-a-doctor. We also expect any additional specialists you appoint to follow the ethical guidance in connection with treatment provided by you.
This guidance states, in paragraph 78, domain 4, under the section "Honesty in financial dealings", that: "You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients."
We do not expect you to redirect a patient's care or cancel treatment if you are unable to agree your preferred fee with us. We will take situations like this seriously and we may withdraw your recognition in these circumstances.
3.2 - Unproven Treatment
We do not provide benefit for experimental or unproven treatments. These are treatments which do not meet our definition of conventional treatment, as defined below. These treatments include those using new technology or drugs, where safety and effectiveness have not been established or generally accepted. We may make a contribution to unproven treatment if there is a suitable, equivalent conventional treatment.
Please contact our Medical Support Team (medicalsupportteam.health@axahealth.co.uk) before undertaking treatment which might be considered unproven. Please send us:
- your details
- the appropriate CCSD code
- a description of what you will be doing during surgery
- date of surgery
- the hospital where the treatment will take place
- who will be present during surgery, including the anaesthetist's name and provider number
- the patients name, date of birth and membership details.
You should not use codes covering existing procedures for new and as yet uncoded procedures.
Conventional Treatment
We define conventional treatment as treatment that:
- is established as best medical practice, is practised widely within the UK and
- is clinically appropriate in terms of necessity, type, frequency, extent, duration and the facility or location where the treatment is provided; and has either
- been shown to be safe and effective for the treatment of the medical condition through substantive peer reviewed clinical evidence in published authoritative medical journals or
- been approved by the National Institute for Health and Care Excellence (NICE) as a treatment which may be used in routine practice.
If the treatment is a drug, the drug must be:
- licensed for use by the European Medicines Agency or
- the Medicines and Healthcare products Regulatory Agency and
- used according to that licence.
4: Specific Provisions
4.1 - Anaesthesia Provisions
Anaesthesia reimbursement includes:
- pre-operative assessment, on the ward or at a clinic
- the anaesthetic itself, including all intra-operative and post-operative care and any care in an ITU or high dependency unit (HDU) expected during the procedure
- inserting and removing all lines and catheters, including central venous pressure (CVP), arterial (ART), continuous cardiac output (CCO), hemofiltration vascaths, nasogastric and urinary tubes
- monitoring and
- analgesia, including nerve blockage, neuroaxial blockade or patient controlled analgesia.
You should not list any of these items as additional charges.
Following the Guidelines for the Provision of Intensive Care Services jointly published by the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS) (Edition 1.1 2016), we will pay a daily fee as listed in our Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/ to the intensivist caring for a patient in an ITU. This pays for all ITU care including, but not limited to:
- insertion and care of CVP/ART/vascath/pulmonary artery catheters
- dialysis/haemofiltration
- chest drains and
- tracheostomy insertion or endotracheal tube changes.
We will not pay this fee to the anaesthetist present during the surgery.
4.2 - Injections And Infusions
As they are not separate surgical procedures, we do not accept separate charges for:
- subcutaneous, intramuscular or intravenous injections, including vaccinations where eligible
- drug/electrolyte infusions, including blood/fresh frozen plasma/platelets.
We include injections and infusions within our standard consultation or hospital fee, whether given during a planned consultation or by appropriate nursing staff during a hospital stay.
4.3 - Chemotherapy And Radiotherapy
Charges for the prescribing and supervision of chemotherapy should be made in accordance with the schedule set out in Chapter 18 of our Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/
Consultation
A fee for consultation may be charged before treatment commences. Further consultation fees should not be charged during the course of treatment.
Chemotherapy
The coding covers all care relating to the clinical supervision and planning of the delivery of chemotherapy (only ONE of the following: X0001 OR X0002 OR X0003 OR X0004) regimens and the engagement and management of patients, including but not limited to:
- regime prescription
- supervision of planning and treatment delivery
- expected side effects management and the prescription of an alternative regimen
- supervision of all outpatient, day patient, and inpatient care.
Only one supervision fee will be paid for any course of treatment regardless of whether a single or multiple drug combination is used. We expect that invoices for chemotherapy and biological supervision should be made at the end of the cycle of treatment.
We will pay a chemotherapy supervision fee when a member is receiving chemotherapy as an in patient. We will not pay consultation fees in addition to chemotherapy supervision fees during this time.
We will not pay for a consultation while a member is receiving chemotherapy treatment as an out patient or day case.
Oncologists can charge the daily in-patient physicians fee for each day the member is in hospital due to side effects of chemotherapy when the treatment has stopped.
Consultations can only be billed when there is a break in treatment and the date of the final chemotherapy supervision treatment has passed.
When a member is on long term maintenance treatment, we will not pay for follow up consultations unless there is a break in treatment and no supervision fee has been paid that cover the date of the consultation.
Radiotherapy
Charges for the prescribing and supervision of radiotherapy should be made in accordance with the schedule set out in Chapter 20.
As per CCSD guidance, it is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Please see the CCSD Schedule for more information: https://www.ccsd.org.uk/ccsdschedule/CCSDScheduleCode?Chapter=20&Section=0&subsection=0&ctype=0&numitems=100&page=0
A fee for consultation may be charged before treatment commences. Further consultation fees should not be charged during the course of treatment. These codes cover all care relating to the clinical supervision and planning of the delivery of radiotherapy regimens and the engagement and management of patients, including but not limited to:
- regime prescription
- supervision of planning and treatment delivery
- expected side effects management and the prescription of an alternative regimen
- supervision of all outpatient, day patient, and inpatient care, including any transfusion of blood/blood products.
We expect that invoices for radiotherapy supervision and treatment delivery should be made at the end of the cycle of treatment.
5: Administration And Governance
5.1 - Submitting Invoices
You must submit all invoices to us for eligible claims within six months of treatment. Please do not send patients invoices or seek payment from them directly.
To help us to pay you promptly, please submit invoices electronically via our e-billing provider Healthcode https://www.healthcode.co.uk/medical-billing/billing. When you open this link you should select the option to "register for ePractice".
5.2 - Payment
We send you remittance advice telling you the total amount we are paying you for treatment, which patient the payment relates to and any reasons the invoice wasn't paid in full (for example, if there was a membership limitation).
Your patients receive similar statements advising them of any costs their membership doesn't cover, which they must settle with you.
To ensure patients can pay you quickly, please let us share your bank details with your patients by filling out this consent form on our Provider website https://provider.axahealth.co.uk/specialist-opt-in-form/. This lets us share your bank details when needed.
We will also send your patients the invoice address you gave us when you became recognised. Please ensure it is an address you are happy for your patients to know (a business, rather than a home address, for example). If you would like us to use a different address, please update your details on the Private Practice Register PPR: https://www.theppr.org.uk/
5.3 - Requests For Medical Documentation
During your patient's treatment we may request medical information or documentation to make a decision about a claim. We will let you know where to send this information when we request it.
As the treating provider, we hold you responsible for ensuring the information you provide, such as coding or medical notes, is accurate. This is important as we use this information to agree treatment for patients and settle their claims quickly.
We expect you to comply with the good practice guidance of your regulatory authority when submitting this information.
For example, the general medical record keeping standards of the Royal College of Physicians expect "every entry in the medical record should be dated, timed (24 hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated and timed". https://www.rcplondon.ac.uk/projects/outputs/generic-medical-record-keeping-standards
We expect your documents to be complete, accurate, clear and signed by you. They should include details of procedures, treatments or consultations as appropriate and include the patient's name, relevant dates and treatment start and end times.
If you submit documents or information that do not adhere to these standards, we will not be able to review them and we cannot consider your request. If in doubt, please supply typed notes with the original copies.
Please note:
- we will ask for this information to be submitted as soon as possible, but no later than 28 days after we have asked for it
- it is your responsibility to gain your patient's consent to share this information
- without this consent, we may not be able to review the information you have sent us
- we try to request the minimum appropriate information needed to make a decision
- under the General Data Protection Regulation (GDPR), you are the controller of this information and you are responsible for ensuring you send the correct information to us.
We do not pay you for providing this information or for completing reports.
We may audit medical notes as part of our quality control procedures. Once the member signs a consent form authorising this disclosure, we will ask you to provide us this information.
5.4 - Fraud And Misrepresentation
The Fraud Act 2006 sets out the legal definition of fraud and creates offences of fraud by false misrepresentation, fraud by omission and fraud by abuse of position. A person who makes a false statement, omits material facts or misuses a position of trust with the intention of causing loss to a third party is guilty of fraud even if he or she does not personally gain and even if the deception fails. The law includes false statement made to any device capable of receiving information. Home Office guidance on the application of the Act states that it is intended to cover false statements made to insurance companies at underwriting.
Our business is conducted on the basis of good faith. We monitor claims using data mining software and routinely audit claims by reference to medical records. We will not tolerate fraud and misrepresentation and will cease doing business with any provider who provides false, misleading or selective information. We will also refer cases of fraud to the GMC and to the police as appropriate. We consider the following examples constitute fraudulent billing:
- exaggerating the complexity of the procedure. For example, coding a diagnostic procedure as if it were therapeutic
- misrepresenting the medical history or the procedure performed
- omitting material facts
- using jargon or technical information which, while strictly correct, is presented in a way likely to mislead a non-medically qualified claims assessor: a claim for laser in situ keratomileusis (LASIK), for example, coded as keratoplasty
- unbundling (see section 2.5 on Unbundling, above).
We may share your details under Article 2 of the GDPR for the purposes of the prevention, investigation, detection or prosecution of criminal offences or the execution of criminal penalties, including the safeguarding against and the prevention of threats to public security.
6: Robotic Procedures
6.1 - Robotic Procedures
We are very aware that the use of robotic assistance in surgery is a rapidly expanding field of medicine in both the NHS and private sector, and we have seen the number of robotic assisted surgeries increase since 2023.
We are keen to support our specialists with this change in clinical practice so we have been working with CCSD and our insurer colleagues externally to carry out a comprehensive review of the coding required for robotic procedures.
Following this review we are very pleased to be able to tell you that we have now added a large number of robotic procedure codes to our schedule of fees. These codes have been added to the relevant specialty chapter alongside the conventional procedure coding for ease when searching for a procedure on our schedule.
Unbundling rules apply as per the non robotic conventional equivalent procedure codes.
Not all of our robotic codes are eligible and we do not fund them all so you will need to check with our customer service teams before going ahead with robotically assisted surgery. Where the robotic procedure is not eligible but we allow the conventional equivalent we will provide the appropriate procedure code for you and pay the conventional fee only.
This is great news and allows us to support our specialists and members with the changes and improvements in clinical surgeries.
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
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| 5.3 | Inner ear | ||||
| A8480 | Transtympanic electrocochleography | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1920 | Primary open reduction of long bone with fixation | Major | |||
| 16.11 | Foot | ||||
| W6017 | Ankle arthrodesis with internal fixation | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
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| 11.6 | Rectum/anus | ||||
| H5400 | Anorectal stretch | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
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| 14.5 | Vulva/labia | ||||
| P0580 | Radical vulvectomy (including block dissection of inguinal gland) | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
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| 6.1 | Face and jaws | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W5710 | Excision arthroplasty of first metatarsophalangeal joint, (e.g. Keller, Bonney-Kessel procedures) including cheilectomy | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
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| 16.2 | Bone (non-specific) | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
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| 14.1 | Uterus/adnexa | ||||
| Q0740 | Total abdominal hysterectomy, +/- oophorectomy, +/- ureterolysis | Major | |||
| 14.4 | Vagina/perineum | ||||
| P2450 | Sacrospinous fixation | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
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| 12.3 | Bladder | ||||
| M3410 | Robot assisted laparoscopic cystectomy without prostatectomy (with construction of intestinal conduit or bladder) | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
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| 15.2 | Repair | ||||
| W0960 | Excision of benign tumour of bone with bone grafting | Xmajor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
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| 12.1 | Kidney/renal pelvic | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
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| 4.5 | Conjuctiva | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P1920 | Excision of septum of vagina | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0880 | Amputation through mid-carpal/transmetacarpal | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 25022 | Stellate ganglion block (local anaesthetic) +/- Image Guidance | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5610 | Pancreatoduodenectomy and excision of surrounding tissue (Whipple's procedure) | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.11 | Liver | ||||
| XR580 | Percutaneous cholecystostomy | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2430 | Transabdominal anti-reflux operations | Complex | |||
| 8.8 | Heart – cardiac surgery | ||||
| K2540 | Replacement of mitral valve with sub-valve preservation (including biopsies) | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1040 | Suture of eyebrow (as sole procedure) | Minor | |||
| 4.6 | Cornea | ||||
| C4520 | Excision of lesion of cornea | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5020 | Repair of anal sphincter (including sigmoidoscopy) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7420 | Autograft Anterior Cruciate Ligament Reconstruction +/- Meniscectomy | Xmajor | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5180 | Aorto-bifemoral bypass | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D2050 | Tympanic neurectomy | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| BT222 | Insertion and removal of high dose rate radioactive agent (brachytherapy) into prostate tumour | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6402 | Repair of major nerve | Major | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A3200 | Decompression of cranial nerve (craniotomy) | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M5600 | Therapeutic endoscopic operations on outlet of female bladder (including cystoscopy) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0260 | Rhinoplasty following trauma or excision of tumour (including attention to turbinates) | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| Q1010 | Dilation of cervix uteri and curettage of retained products of conception following miscarriage | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2320 | Transthoracic repair of diaphragmatic hernia (acquired) | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W3090 | Core decompression of knee | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2400 | Transthoracic fundoplication and gastroplasty | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1930 | Alveolar bone graft - unilateral | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1710 | Suture of eyelid (laceration) (as sole procedure) | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W4542 | Open reduction, internal fixation and revision of femoral component for peri-prosthetic fracture | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22000 | Routine electroencephalography (EEG) in adult or child aged over 5 (Including reporting) | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P1300 | Operations on female perineum | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0464 | Complex Procedure To Mid Foot And Hindfoot With Autogenous Bone Graft (Osteotomy/Fusion +/- Tendon Transfers, Fixation) | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| M5300 | Vaginal operations to support outlet of female bladder (including cystoscopy) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6030 | Transection of peripheral nerve for neuroma | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W7910 | Metatarsal Osteotomy (Eg Scarf) For Hallux Valgus, +/- Internal Fixation +/- Soft Tissue Correction - Unilateral | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.3 | Meninges | ||||
| A3810 | Excision of lesion of meninges of brain | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6510 | Carpal tunnel release (open) | Intermediate | |||
| 16.7 | Shoulder | ||||
| W7810 | Open arthrolysis of shoulder contracture +/- manipulation/injection | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| A2952 | Excison of acoustic neuroma (vestibular schwannoma) - tumours less than 2.5cm (performed by single surgeon) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3332 | Anterior resection - high (i.e. colorectal anastomosis above the peritoneal reflection) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| X2262 | Complex open reduction for congenital dislocation of hip (i.e. pelvic and femoral or Pemberton osteotomy or revision of open reduction) | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| T6213 | Soft tissue operations in the region of the greater trochanter (trochanteric bursitis, snapping hip) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0410 | Drainage of haematoma/abscess of pinna | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0283 | Total excision of trapezium with spacer | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K1100 | Closure of defect of interventricular septum | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0210 | Excision of lesion of pinna | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N2840 | Repair of avulsion of penis | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| T1220 | Drainage of pleural cavity | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2530 | Repair of rectovaginal fistula | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.3 | Meninges | ||||
| A3900 | Repair of dura | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| F0312 | Primary closure of cleft lip - unilateral | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7314 | Repair of distal hypospadia | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6810 | Neurolysis and transposition of peripheral nerve (excludes carpal tunnel release) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G7530 | Closure of ileostomy (as sole procedure) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6302 | Graft to major nerve | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.5 | Vessels | ||||
| A0260 | Excision of arteriovenous malformation from vessels of brain | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.12 | General | ||||
| C8650 | Fluorescein angiography of eye (including ocular photography) | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.7 | Teeth | ||||
| F1810 | Enucleation of cyst of jaw | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7340 | Repair of urethrorectal fistula | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.3 | Duodenum | ||||
| G5010 | Open excision of congenital lesion of duodenum including malrotation | Complex | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| J6730 | Endoscopic upper gastrointestinal ultrasound, eg for pancreaticobiliary diagnosis/transmucosal biopsy | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7330 | Closure of fistula of urethra (including cystoscopy) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W7530 | Repair of lateral collateral ligament complex | Major | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9113 | Percutaneous insertion of central venous dialysis line | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T1620 | Plication of paralysed diaphragm | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1140 | Correction of telecanthus | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| XR516 | Angioplasty of iliac artery, +/- insertion of stent | Major | |||
| 17.8 | Spine | ||||
| XR530 | Fluoroscopically guided percutaneous vertebroplasty | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| T6763 | Repair of tendon of foot – extensor Minor | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S6400 | Excision of nail bed (Zadik's) (including anaesthetic) | Intermediate | |||
| 15.2 | Repair | ||||
| S4930 | Removal of skin expander or valve (not related to breast reconstruction) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A5530 | Lumbar puncture (including spinal manometry) | Minor | |||
| 3.6 | Peripheral nerves | ||||
| A6402 | Repair of major nerve | Major | |||
| 3.6 | Peripheral nerves | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1432 | FESS Uncinectomy, ethmoidectomy, antrostomy or antral puncture inc polypectomy and attention to turbinates etc | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3365 | Laparoscopic anterior resection - low (ie colorectal anastomosis at or below the peritoneal reflection) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T0320 | Exploratory thoracotomy | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1420 | Graft of skin to eyelid | Intermediate | |||
| 4.5 | Conjuctiva | ||||
| C3910 | Excision/biopsy of conjunctival lesion | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1000 | Excision of sigmoid colon | Xmajor | |||
| 11.6 | Rectum/anus | ||||
| H5640 | Excision of anal fissure | Minor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G7900 | Ileoscopy via stoma with therapy | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3102 | Revisional combined anterior discectomy and posterior fusion (thoracic region) Including Spinal Cord Monitoring | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W6600 | Closed reduction of dislocated hip prosthesis | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| A2954 | Excision of acoustic neuroma (vestibular schwannoma) - tumours managed by combined oto-neurosurgical team irrespective of tumour size | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K4600 | Off-pump coronary artery bypass (OPCAB) (including harvesting of grafts) | Complex | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8520 | Block dissection of axillary lymph nodes (axillary clearance levels 1-3) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0140 | Excision of preauricular sinus | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR352 | Embolisation of artery/vein | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M6620 | Endoscopic incision of outlet of male bladder (with cystoscopy) | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| T6810 | Delayed or Secondary Repair Of Achilles Tendon Without Tendon Or Fascial Graft | Major | |||
| 9 | Vascular system | ||||
| 9.1 | Head and neck | ||||
| L3710 | Bypass of subclavian artery from the arch | Complex | |||
| 9.2 | Thoracic vessels | ||||
| L2290 | Excision of infected aortic graft with bypass | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E1910 | Total pharyngectomy | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.12 | Urinary | ||||
| XR640 | Percutaneous creation of track to kidney for nephrolithotomy +/- insertion of stent | Xmajor | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2915 | Reconstruction of breast using extended latissimus dorsi flap (including delayed reconstruction) | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6450 | Removal of foreign body from iris | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.7 | Other nerve blocks | ||||
| AA460 | Destruction of branch of trigeminal nerve (neurolytic/RF/cryoprobe) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E4030 | Tracheoplasty | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6710 | Cubital tunnel release (open) (without transposition) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6914 | Tenolysis of extensor tendon of hand | Intermediate | |||
| 16.7 | Shoulder | ||||
| W9111 | Manipulation of joint (including intra-articular injection) for “Frozen Shoulder” (as sole procedure) – bilateral | Intermediate | |||
| 16.11 | Foot | ||||
| W7880 | Open or arthroscopic release of ankle joint contracture (excluding Achilles tendon lengthening) | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR910 | Insertion of central venous catheter - non-tunnelled (X-ray guided) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4302 | Combined anterior vertebrectomy with posterior fusion and instrumentation | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T6800 | Delayed or secondary repair of tendon (including graft, transfer and/or prosthesis) (not otherwise specified) | Major | |||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9017 | Yttrium joint injection (with radioactive precautions) | Minor | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5300 | Open operations on iliac artery | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| F4230 | Removal of excess mucosa from mouth | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0730 | Removal of foreign body from external auditory canal (and bilateral) | Minor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.6 | Other | ||||
| B0610 | Excision of pineal gland | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K0700 | Correction of total anomalous pulmonary venous connection | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2202 | Ureterostomy - formation | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| 25030 | Stellate ganglion block (neurolytic) +/- Image Guidance | Minor | |||
| 3.8 | Other procedures | ||||
| X3770 | Intramuscular injection(s) with X-ray control (eg piriformis block) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.8 | Major vessels | ||||
| L7920 | Plication of vena cava | Xmajor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S3100 | Re-exploration of free flap | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7600 | Lumbar sympathectomy therapeutic (neurolytic under X-ray control) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G4010 | Pyloromyotomy | Major | |||
| 11.4 | Small intestine | ||||
| G6082 | Open resectionof small intestine tumour | Major | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| R2510 | Caesarean hysterectomy | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0610 | Open removal of calculi from kidney | Major | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| J3900 | Therapeutic ERCP with insertion of biliary or pancreatic stent(s), sphincterotomy or stone extraction | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A1300 | Maintenance of cerebroventricular shunt | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| C3180 | Revision of squint surgery | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2210 | Total glossectomy | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2542 | Posterior excision of disc prolapse with undercutting facetectomy +/- decompression - lumbar region (1 or 2 levels) | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L0900 | Formation of cavo-pulmonary shunt (Glenn) | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6900 | Revision of release of peripheral nerve | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| T8580 | Block dissection of pelvic lymph nodes (as sole procedure) | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S5535 | Dressing of burn of skin or subcutaneous tissue - greater than 25% | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2331 | Laparoscopic repair of hiatus hernia with anti-reflux procedure (eg fundoplication) | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L2303 | Coarctation repair involving prosthetic graft | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0210 | Hemihepatectomy (resection of four or more segments) +/- cholecystectomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W5930 | Fusion of digit joint(s) of hand with or without graft and with or without internal fixation | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E2480 | Endoscopic operation(s) on pharyngeal pouch (e.g. Dohlman's procedure) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T0212 | Secondary correction of scolios-related chest wall deformity (posterior costoplasty) (as sole procedure) | Complex | |||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1150 | Removal of internal fixation and/or inter-maxillary fixation from jaw | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3362 | Hartmann's procedure | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W8240 | Meniscal allograft transplantation | Xmajor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| XR254 | Angioplasty of other arteries (e.g. sub-clavian, tibial, femoro-popliteal) including peripheral angiogram +/- insertion of stent | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A4832 | Implantation of spinal cord stimulator | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.7 | Teeth | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E4230 | Mini-tracheostomy (percutaneous) | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.8 | Spine | ||||
| XR500 | Chemonucleolysis | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2430 | Revisional posterior decompression with fusion (thoracic region) Including Spinal Cord Monitoring | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0642 | Excision of lesion of skin or subcutaneous tissue - four or more, Head & Neck (excluding lipoma) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6710 | Cubital tunnel release (open) (without transposition) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3602 | Enterocystoplasty (including cystoscopy) | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C4650 | Revision of corneal graft/wound | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W8620 | Therapeutic arthroscopy examination of hip joint, +/- biopsy | Xmajor | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2987 | Reconstruction of breast using Transverse Upper Gracilis (TUG) flap (including delayed reconstruction and nipple reconstruction) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W8602 | Therapeutic arthroscopy of wrist joint (sole procedure) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| BT210 | Oral introduction of liquid radioactive agent for malignant thyroid tumour ablation | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1890 | Repair of leaking aneurysm of thoracic aorta | Complex | |||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L1990 | Elective repair of aneurysm of thoracic aorta | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S2503 | Local flap ? 9cm2 or more (including graft/flap to secondary defect) | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A5110 | Excision of intradural lesion | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H4430 | Examination of rectum under anaesthetic (as sole procedure) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4000 | Combined anterior and posterior correction and instrumentation, +/- fusion of idiopathic juvenile scoliosis (including spinal monitoring) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W6030 | Revision or conversion to arthrodesis of shoulder | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5620 | Lateral sphincterotomy of anus | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| 25100 | Coeliac plexus block, splanchnic nerve block, hypogastric block - diagnostic +/- Image Guidance | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T4130 | Freeing of adhesions of peritoneum | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.6 | Dilatation | ||||
| XR565 | Percutaneous dilatation of biliary stricture under imaging control | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1646 | Open reduction/internal fixation of sacro-iliac joint | Complex | |||
| 16.7 | Shoulder | ||||
| W4930 | Revisional shoulder hemiarthroplasty | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2930 | Vertical hemi-laryngectomy | Complex | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L0620 | Creation of communication between pulmonary artery and aorta | Complex | |||
| 8.11 | Other | ||||
| 64302 | Transoesophageal echocardiography (including reporting) (as sole procedure) | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0200 | Excision of lesion of tissue of brain | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| F3240 | Operations on uvula | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0950 | Plastic reconstruction of uterus | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0310 | Resection of liver tumour(s) | Complex | |||
| J2800 | Excision of lesion of bile duct | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| G0922 | VATS oesophageal / oesophagogastric myotomy | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| X4810 | Change of cast without general anaesthetic (as sole procedure) | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2660 | Tongue flap - first stage and second stage | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W8580 | Multiple arthroscopic operations on knee (including meniscectomy, chondroplasty, drilling or microfracture) - bilateral | Complex | |||
| 16.11 | Foot | ||||
| T6461 | Tendon transfer of toe – bilateral | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S4230 | Secondary suture of skin | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.12 | Urinary | ||||
| XR650 | Percutaneous pyelolysis | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| T7290 | Trigger point injection/Enthesis - one injection | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W5030 | Revision total shoulder replacement | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L1890 | Repair of leaking aneurysm of thoracic aorta | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| XR252 | Venoplasty | Major | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8700 | Excision biopsy of lymph node for diagnosis (cervical, inguinal, axillary) | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2110 | Temporomandibular meniscectomy | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| T7930 | Repair of abductor mechanism of hip | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S3530 | Split autograft of skin, trunk and limbs ? over 25cm2 and up to 5% of body surface area | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8300 | Therapeutic Arthroscopy Operation On Articular Cartilage (Other Than W8200) - Unilateral (As Sole Procedure) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4830 | Therapeutic sialendoscopy (including washout) | Intermediate | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7420 | Creation of arteriovenous fistula (including subsequent closure) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2920 | Endoscopic insertion/removal of prosthesis into ureter (including bilateral and cystoscopy, +/- pyelography) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0720 | Disarticulation of shoulder | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3181 | Prosthetic intervertebral disc replacement in the thoracic spine including spinal cord monitoring | Complex | |||
| 3.6 | Peripheral nerves | ||||
| A6080 | Neurectomy (major nerve) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.11 | Other | ||||
| A2720 | Proximal gastric vagotomy | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E3410 | Laser surgery to vocal cord (including microlaryngoscopy) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W6012 | Primary arthrodesis of joint with or without graft and with or without internal fixation – shoulder | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q3900 | Laparoscopy (including e.g. puncture of ovarian cysts, +/- biopsy, minor endometriosis, +/- ureterolysis) | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 22000 | Routine electroencephalography (EEG) in adult or child aged over 5 (including reporting) | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| C8440 | Retinal examination under anaesthetic including retinopexy if necessary | Minor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 25010 | Paravertebral block up to two levels (without X-ray control) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1700 | Intra abdominal manipulation of colon for intussusception (as sole procedure) | Major | |||
| 11.9 | Abdominal wall | ||||
| T2112 | Laparoscopic repair of recurrent inguinal hernia - bilateral | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0380 | Nasal septum cauterisation (and bilateral) | Minor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A2952 | Excison of acoustic neuroma (vestibular schwannoma) - tumours less than 2.5cm (performed by single surgeon) | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q4400 | Ovarian cystectomy +/- omental biopsy (as sole procedure and including bilateral) | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S3532 | Split autograft of skin, trunk and limbs ? each additional 5% of body surface area | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T1640 | Repair of congenital diaphragmatic hernia | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3900 | Open removal of calculus from bladder (including cystoscopy) | Intermediate | |||
| 12.4 | Urethra | ||||
| 12.6 | Genitalia | ||||
| N1000 | Prosthesis of testis (insertion or removal) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2952 | Laryngofissure | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H4080 | Injection of bulking agents for faecal incontinence | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1330 | Biopsy of lesion of facial bone | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S5534 | Dressing of burn of skin or subcutaneous tissue - 10% - 25% | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| T1300 | Introduction of substance into pleural cavity with chest drain | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0520 | Microscopically controlled excision of lesion of skin or subcutaneous tissue (Mohs micrographic surgery) with immediate reconstruction | Xmajor | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8621 | Ultrasound-guided foam Sclerotherapy for varicose vein(s) ? bilateral | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| E6310 | Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal masses | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N0680 | Orchidectomy and excision of spermatic cord (+/- insertion of prosthesis) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| A2720 | Proximal gastric vagotomy | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.11 | Other | ||||
| X5020 | External cardioversion | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1380 | Percutaneous tru-cut needle biopsy of lesion of kidney | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.8 | Neck | ||||
| T8723 | Selective dissection of cervical lymph nodes, levels 1 to 5 (+/- 6) | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7500 | Lumbar sympathectomy diagnostic (local anaesthetic under X-ray control) | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3610 | Gastropexy for reflux | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| C3780 | Injection of botulinum toxin into extraocular or periocular muscles | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.8 | Neck | ||||
| T8510 | Radical dissection of cervical lymph nodes | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7530 | Removal of lens implant | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W5980 | Fusion of interphalangeal joint(s) of toe (including internal fixation) – bilateral | Major | |||
| 16.12 | External fixation/traction | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S5533 | Dressing of burn of skin or subcutaneous tissue - 2% - 10% | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5740 | Ablation of ventricular arrhythmia (including mapping) | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| C3950 | Radiotherapy to conjunctival lesion | Minor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A2954 | Excision of acoustic neuroma (vestibular schwannoma) - tumours managed by combined oto-neurosurgical team irrespective of tumour size | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3180 | Implantation of prosthesis into breast as sole procedure | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.3 | Trachea | ||||
| E4032 | Tracheoplasty for congenital conditions | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T7010 | Percutaneous tenotomy | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.11 | Other | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0434 | Isolated Subtalar Fusion Or Midfoot Fusion Without Autogenous Graft | Major | |||
| 9 | Vascular system | ||||
| 9.1 | Head and neck | ||||
| L3711 | Bypass of subclavian artery - extra-thoracic | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W7860 | Arthroscopic arthrolysis of elbow (as sole procedure) | Major | |||
| 16.13 | Amputation | ||||
| X0930 | Amputation of leg above the knee | Major | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| Y3810 | Insertion of indwelling pleural catheter | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3420 | Laparoscopic cystectomy (with construction of intestinal conduit or bladder) (including cystoscopy) | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1910 | Elective repair of aneurysm of ascending aorta | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 12.4 | Urethra | ||||
| M7380 | Repair of rupture of urethra (including cystoscopy) | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0110 | Exenteration of orbit | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4510 | Diagnostic endoscopic examination of bladder (flexible cystoscopy) including any biopsy | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| T8950 | Repair of peri-lymph fistula | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3580 | Laparoscopic closure of peptic ulcer | Major | |||
| 11.7 | Other organs (mainly digestive) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W5540 | Debridement of infected total joint replacement | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0680 | Drainage of pyonephrosis | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K5120 | Intravascular ultrasound of coronary arteries (as sole procedure) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W6013 | Primary arthrodesis of hip joint with or without graft and with or without internal fixation ? hip | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E5592 | VATS lung volume reduction - unilateral | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1813 | Correction of ptosis of eyelid with autologous fascia lata | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4320 | Endoscopic hydrostatic distention of bladder (including cystoscopy) | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| T7981 | Extensive, greater than 2cm tear repair of large muscle including arthroscopic (excluding rotator cuff) | Major | |||
| 16.12 | External fixation/traction | ||||
| W3010 | Application of external fixation to bone | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F5110 | Open extraction of calculus from parotid duct | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4310 | Endoscopic transection of bladder (including cystoscopy) | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8620 | Sampling of axillary lymph nodes | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR968 | Colonic stent insertion | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3350 | Combined anterior approach discectomy, decompression and fusion and posterior fusion (lumbar region) including spinal cord monitoring | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0810 | Polypectomy of internal nose (and bilateral, including endoscopic) | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22023 | Recording and reporting on electromyography and nerve conduction studies (EMG); Mononeuropathy (eg ulnar), Cx/Lumbar radiculopathy, Myopathy | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.5 | Vulva/labia | ||||
| P0600 | Excision of lesion of vulva | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1910 | Primary reduction of fracture of neck of femur and internal fixation | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3334 | Anterior resection - low (ie colorectal anastomosis at or below the peritoneal reflection | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T6980 | Tenolysis, of flexor tendon (not otherwise specified) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22005 | 24 hour video telemetry Electroencephalography (EEG) (Including reporting) | Minor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| W9040 | Injection(s) +/- aspiration, into joint, cyst, bursa - unilateral | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2652 | Revision posterior fusion +/- instrumentation (lumbar region) including spinal cord monitoring | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G1400 | VATS excision lesion of oesophagus | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1590 | Open formation of colostomy | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L2350 | Revision operation on ascending aorta and proximal descending aorta | Complex | |||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L1892 | Immediate repair of aortic dissection (ie within two weeks of happening) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8513 | Endovenous laser treatment (EVLT) of single venous trunk +/- phlebectomies - bilateral | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0910 | Endoscopic fragmentation of calculi of kidney (including cystoscopy and insertion/removal of stent) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1082 | Partial maxillectomy for malignancy | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| W1870 | Drainage of petrous apex for sepsis | Complex | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5210 | Endarterectomy and patch repair of iliac artery | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0400 | Open excision of lesion of oesophagus | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6710 | Cyclodialysis (separation of ciliary body) | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G8082 | Diagnostic oesophago-gastro-duodenoscopy (OGD) and immediate colonoscopy includes forceps biopsies, biopsy test and dye spray (as sole procedure) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0510 | Open drainage of liver | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1422 | Extensive segmental excision of mandible | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8600 | Therapeutic arthroscopy operation on cavity of joint (not otherwise specified) (as sole procedure) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7316 | Complex secondary repair of hypospadias | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C4640 | Descemets stripping endothelial keratoplasty (DSEK) | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| B2880 | Excision biopsy of breast lesion after localisation | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A7310 | Biopsy of peripheral nerve | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E5432 | VATS lobectomy | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S5560 | Release of burn scar contracture, head, neck, hands, feet and genitalia | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4800 | Therapeutic bronchoscopy (including laser, cryotherapy, lavage, snare, dilatation of stricture, insertion of stent) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| T7604 | Vein/artery graft of part of microvascular free tissue transfer | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N0700 | Excision of lesion of testis | Intermediate | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8515 | Endovenous laser treatment (EVLT) of more than one venous trunk +/-phlebectomies - bilateral | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J2720 | Partial excision of bile duct and anastomosis of bile duct to duodenum/jejunum | Xmajor | |||
| 11.10 | Peritoneum | ||||
| T3010 | Laparotomy for postoperative haemorrhage | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3945 | Open reduction and internal fixation for periprosthetic fracture around hip | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0360 | Septoplasty of nose (including attention to turbinates) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L2600 | Percutaneous transluminal balloon operations on aorta | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A7011 | Trial of neurostimulator to peripheral nerve (as sole procedure) not at time of permanent implant | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3732 | Revision of uncemented or cemented total hip replacement without adjunctive procedures - unilateral | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| L2382 | Aortic root replacement with valve conduit or homograft and/or remodelling | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0300 | Sub-total oesophagectomy with anastomosis in neck | Complex | |||
| 11.7 | Other organs (mainly digestive) | ||||
| J3500 | Sphincterotomy of bile duct and pancreatic duct using duodenal approach | Major | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2991 | Laparoscopic mobilisation of the greater omentum for reconstruction of breast (including delayed reconstruction) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| 5.6 | Throat | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| T7620 | Free functioning muscle transfer (as sole procedure) including closure of secondary defect | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A7010 | Implantation of neurostimulator to peripheral nerve | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T0132 | Excision of chest wall tumour - with chest wall reconstruction | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5800 | Drainage through perineal region (including ischiorectal abscess) (including sigmoidoscopy) | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E2330 | Removal of lesion of para-pharyngeal space | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W4600 | Prosthetic replacement of head of femur | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2730 | Ureteroscopic extraction of calculus of ureter (including cystoscopy and insertion/removal of stent) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4100 | Posterior correction of idiopathic juvenile scoliosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6582 | Transperineal template-guided biopsies of the prostate under image guidance | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2544 | Revision of posterior excision of disc prolapse (lumbar region) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1400 | Open puncture of liver | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1990 | Elective repair of aneurysm of thoracic aorta | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0640 | Closure of bypass of oesophagus | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4480 | Resection of bladder neck (including cystoscopy) | Intermediate | |||
| M4712 | Bladder instillation of pharmacologic agent (including cystoscopy) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0280 | Laparoscopic appendicectomy | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.12 | General | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W2702 | Epiphysiolysis (eg Langenskiold procedure) | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V0910 | Open reduction and fixation of nasal ethmoidal fracture | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V5002 | Manipulation of spine under GA/IV sedation (sole procedure) | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| 16.3 | Fractures | ||||
| W2830 | Removal of internal fixation from bone/joint, excluding K-wires +/- Image Guidance | Intermediate | |||
| 16.7 | Shoulder | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.8 | Spine | ||||
| XR540 | CT guided percutaneous vertebroplasty | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0180 | Excision of abscess of brain | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0602 | Primary excision of malignant lesion - head and neck | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0800 | Other open operations on kidney | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
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| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W7881 | Release of contracture of interphalangeal joint of finger (excluding trigger finger or Dupuytren's disease) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7620 | Removal of foreign body from urethra | Minor | |||
| 12.6 | Genitalia | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5730 | Ablation of right atrial arrhythmia (including mapping) | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.6 | Other | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1350 | Closure of oro-antral fistula with local flap | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E5593 | VATS lung volume reduction - bilateral | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.5 | Vulva/labia | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| W0660 | Coccygectomy (multiple levels) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W2580 | Closed reduction of fracture of short bone with external fixator | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8510 | Ligation/stripping of long or short saphenous vein (including local excision/multiple phlebectomy) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7700 | Diagnostic endoscopic examination of urethra (as sole procedure) (including cystoscopy) | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0910 | Excision of lesion of external nose | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W3620 | Open bone biopsy as sole procedure | Intermediate | |||
| 16.12 | External fixation/traction | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| J4300 | Diagnostic ERCP (includes forceps biopsy) | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.10 | Vitreous | ||||
| C7922 | Pars plana vitrectomy/vitreous biopsy | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M5180 | Revision combined abdominal and vaginal operations to support outlet of female bladder (including sling procedures and cystoscopy) | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K1200 | Norwood stage 1 procedure | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6150 | Revision of previous glaucoma surgery (including topical local anaesthetic) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1644 | Open reduction/internal fixation of both columns of acetabulum | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5532 | Thoracotomy and lung biopsy as sole procedure | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W3202 | Open reduction and internal fixation wedge reconstruction bone graft scaphoid non-union | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0700 | Right hemicolectomy | Xmajor | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3015 | Reconstruction of breast using fixed prosthesis (including delayed reconstruction) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0850 | Removal of foreign body from cavity of nose | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 8.9 | Heart – cardiology | ||||
| K6100 | Insertion of single chamber implantable cardioverter defibrillator (ICD) | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0900 | Implantation of neurostimulator to brain | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W2582 | Closed reduction of fracture of short bone (including cast or percutaneous K-wires) | Intermediate | |||
| W3050 | Adjustments to pin sites secondary for non-union/mal-union Minor | Minor | |||
| 16.11 | Foot | ||||
| W5700 | Excision Arthroplasty Of First Metatarsophalangeal Joint With Prosthetic Implantation Or Interpositional Arthroplasty - Unilateral | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F5510 | Dilatation of parotid duct | Minor | |||
| 6.7 | Teeth | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G4530 | Catheterless oesophageal pH monitoring (eg Bravo) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8592 | Laparoscopic retroperitoneal lymph node dissection | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T5223 | Dupuytren’s dermofasciectomy and graft, or for recurrent disease – multiple digits | Major | |||
| 16.10 | Knee | ||||
| W0632 | Prosthetic Patello-Femoral Replacement - Unilateral (As Sole Procedure) | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| M3710 | Cystourethroplasty (including cystoscopy) | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T3410 | Open drainage of subphrenic abscess | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4440 | Excision of submandibular gland | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3122 | Revisional transthoracic/antero-lateral excision of intervertebral disc +/- fusion including spinal cord monitoring | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0410 | Wide excision of sweat glands -including bilateral axillae | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4450 | Excision of sublingual gland | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W3200 | Open reduction and internal fixation of cancellous bone graft scaphoid non-union | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B0813 | Total thyroidectomy including block dissection of lymph nodes | Major | |||
| B0830 | Unilateral Total Thyroid Lobectomy & Isthmectomy +/- Microlaryngoscopy/Laryngoscopy | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4120 | Anterior correction of idiopathic juvenile scoliosis with instrumentation, +/-fusion (including spinal cord monitoring) (Excluding vertebral body tethering VBT) | Complex | |||
| 3.6 | Peripheral nerves | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0132 | Excision accessory auricle/preauricular appendage | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2310 | Excision of cardiac tumour | Complex | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W8880 | Arthroscopy of elbow (as sole procedure) | Major | |||
| 16.11 | Foot | ||||
| W0861 | Metatarsophalangeal Cheilectomy - Bilateral, As Sole Procedure | Xmajor | |||
| 16.13 | Amputation | ||||
| X0750 | Amputation of arm | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| AA460 | Destruction of branch of trigeminal nerve (neurolytic/RF/cryoprobe) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.6 | Dilatation | ||||
| XR450 | Dilatation of stricture under imaging control | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4453 | Balloon kyphoplasty - greater than two levels | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1260 | Image guided endoscopic frontal, sphenoid and/or ethmoid sinus surgery (FESS) and bilateral | Major | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| R1210 | Transvaginal cerclage of cervix of gravid uterus | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1440 | Combined approach tympanoplasty - intact canal wall tympanoplasty | Major | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4300 | Anterior vertebrectomy with decompression and implant | Complex | |||
| 3.9 | Neurophysiological procedures | ||||
| 22024 | Recording and reporting on electromyography and nerve conduction studies (EMG); Mononeuritis Multiplex, MND-AHC, Multiple Muscle Monitoring (eg Torticollis), Myaesthenia Gravis (- SFEMG) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1080 | Open operations/repair of pulmonary artery | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2210 | Open correction vesicoureteric reflux-unilateral | Major | |||
| M3202 | Operations on ureteric orifice (including endoscopic) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| XR100 | Fluoroscopically guided biopsy(ies) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W5510 | Total prosthetic replacement of elbow | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3100 | Combined anterior discectomy and posterior fusion (thoracic region) Including Spinal Cord Monitoring | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| M5582 | Diathermy of urethral caruncle | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6082 | Removal of pacing system (generator only) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W8520 | Arthroscopy of knee (including examination under anaesthetic, washout and biopsy) (as sole procedure) | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| F4210 | Biopsy of lesion of mouth | Minor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0580 | Repair of compound fracture of cranium | Xmajor | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9110 | Insertion of tunnelled central venous catheter (Hickman Line) | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q2230 | Laparoscopic oophorectomy and salpingectomy, +/- biopsy eg. omentum, peritoneum, lymph node (as sole procedure) - bilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W5512 | Prosthetic replacement of radial head | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| C2610 | Excision/biopsy of lacrimal sac | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4410 | Total excision of parotid gland and preservation of facial nerve | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 12.3 | Bladder | ||||
| M5100 | Combined abdominal and vaginal operations to support outlet of female bladder (including sling procedures) (including cystoscopy) | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0750 | Subtotal abdominal hysterectomy, +/- oophorectomy, +/- ureterolysis | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7530 | Laparoscopic lumbar sympathectomy | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H4800 | Excision of lesion of anus | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1310 | Percutaneous fine needle biopsy of lesion of kidney | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5042 | Primary repair of high/intermediate congenital ano-rectal anomaly | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2985 | Reconstruction of breast using free TRAM (including delayed reconstruction | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L7042 | Atrial switch procedure for transposition of great vessels | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5220 | Epidural injection (thoracic) | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR963 | Percutaneous chemical ablation of tumour - CT guided | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G4020 | Surgery for correction of congenital intestinal atresias | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6700 | Release of entrapment of peripheral nerve | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K1680 | Transluminal closure of atrial septal defect / patent foramen ovale | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V0830 | Closed reduction and fixation of fractured jaw | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.7 | Other nerve blocks | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| C2640 | Incision of lacrimal sac | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0920 | Myomectomy (including laparoscopically) +/- ureterolysis | Major | |||
| 14.4 | Vagina/perineum | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4990 | Panendoscopy +/- incisional biopsy | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0210 | Nephrectomy and excision of perirenal tissue | Xmajor | |||
| 12.3 | Bladder | ||||
| P2510 | Repair of vesicovaginal fistula (including cystoscopy) | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.5 | Vessels | ||||
| A4080 | Craniotomy – post-operative haemorrhage | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0740 | Repair of ruptured oesophagus | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1810 | Correction of ptosis of eyelid - simple, including tarsomullerectomy | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0500 | Bypass of oesophagus | Xmajor | |||
| 11.10 | Peritoneum | ||||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9114 | Removal of central venous dialysis line | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N1520 | Unilateral epididymectomy | Minor | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0513 | Interpositional silastic arthroplasty of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints ? multiple digits | Major | |||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L1620 | Axillo-unifemoral bypass | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M2981 | Endoscopic vesico-ureteric anti-reflux procedure (and bilateral) (including cystoscopy) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8514 | Endovenous laser treatment (EVLT) of more than one venous trunk +/- phlebectomies - unilateral | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1060 | Revision of mastoidectomy (including meatoplasty) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0880 | Open drainage of perinephric abscess | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| X2260 | Open reduction and Frog POP for congenital dislocation of hip (including traction and innominate/femoral osteotomy) | Complex | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5910 | Femoro-femoral bypass | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2730 | Repair of dorsal hernia including lumbar hernia | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6192 | Robotic assisted radical prostatectomy, reconstruction of bladder neck including bilateral pelvic lymphadenectomy (including cystoscopy) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L6840 | Repair of limb artery using vein graft | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0420 | Reduction turbinates of nose (trim, radical excision) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L2190 | Replacement of graft of thoraco-abdominal aneurysm | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K0400 | Correction of tetralogy of Fallot | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| A8470 | Dynamic laboratory investigation involving measurement of muscle compartment pressures with manometer | Intermediate | |||
| 16.3 | Fractures | ||||
| W1647 | Open reduction/internal fixation of fractures of the greater trochanter, including fixation of non-union of greater trochanter after trochanteric osteotomy | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K4902 | Percutaneous transluminal angioplasty of coronary artery(ies) with intravascular ultrasound (including laser) | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2200 | Ureterostomy - closure | Major | |||
| 12.6 | Genitalia | ||||
| N2880 | Repair of injury to penis | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| L7032 | Haemorrhoidal artery ligation operation (including image-guided) +/- recto anal prolapse repair | Minor | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7280 | Urethral valve resection | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| F3810 | Excision/destruction of lesion of mouth | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.3 | Trachea | ||||
| E3900 | Partial excision of trachea with reconstruction | Complex | |||
| 8.10 | Great Vessels | ||||
| L1880 | Repair of leaking aneurysm of arch of aorta | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| B2984 | Delayed reconstruction of breast using pedicled TRAM | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G7100 | Bypass of ileum | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7320 | Repair of epispadias | Xmajor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S2502 | Local flap ? 9cm2 or more (excluding graft/flap to secondary defect) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1250 | Thyroid: re-operation | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1400 | Excision of mandible | Major | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W0890 | Excision distal clavicle, as sole procedure | Major | |||
| W8820 | Diagnostic arthroscopic examination of shoulder joint, with or without biopsy (as sole procedure) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2312 | Transthoracic repair of paraoesophageal hiatus hernia | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| F0320 | Revision of primary closure of cleft lip | Major | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| V0700 | Cranio-facial resection | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W7715 | Corocoid bone block transfer for recurrent instability of shoulder (Bristow-Latarjet Procedure) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3310 | Abdominoperineal pull through resection with colo-anal anastomosis +/- colonic pouch and associated stoma | Complex | |||
| H4900 | Destruction of lesion of anus | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W3622 | Needle biopsy of bone as sole procedure | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4430 | Partial excision of parotid gland and preservation of facial nerve | Xmajor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7582 | Open surgical stabilisation of patella, including soft tissue/tendon transfer or release, +/- application of cast (child) | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5750 | Internal cardioversion | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0930 | Amputation of leg above the knee | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q1702 | Microwave endometrial ablation including hysteroscopy | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.12 | General | ||||
| C8654 | Insertion of radioactive plaque into eye (including later removal) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1510 | Myringotomy and insertion of tube through tympanic membrane (and bilateral) | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W6230 | Vascular implantation to carpal bone | Xmajor | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7010 | Open embolectomy of artery | Xmajor | |||
| 9.7 | Varicose veins | ||||
| L8512 | Endovenous laser treatment (EVLT) of single venous trunk +/- phlebectomies - unilateral | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0605 | Secondary excision of malignant lesion - trunk and limbs | Intermediate | |||
| 15.2 | Repair | ||||
| 15.3 | Burns, scars and contractures | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1520 | Suction clearance of middle ear (as sole procedure) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0100 | Oesophagectomy/oesophagogastrectomy with anastomosis in chest | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S3624 | Full thickness graft, head, neck, hands and genitalia ? up to 9cm2 in area | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.10 | Vitreous | ||||
| C7920 | Pars plana vitrectomy with internal tamponade, scleral buckling and retinopexy without dissection or excision of epiretinal membrane/macular surgery | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1310 | Antral puncture and wash-out (and bilateral) | Minor | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3014 | Reconstruction of breast using expandable prosthesis (including delayed reconstruction) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3520 | Closure of perforated ulcer of stomach | Major | |||
| 11.4 | Small intestine | ||||
| G6000 | Open formation of jejunostomy | Major | |||
| 11.6 | Rectum/anus | ||||
| H1550 | Abdominal operation for Hirschprung's disease (eg Duhamel, Söave and Surcuson operations) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7410 | Multiple ligament reconstruction of knee | Complex | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2300 | Pharyngeal myotomy | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W5000 | Primary total shoulder replacement | Xmajor | |||
| W4940 | Scapulo-thoracic fusion | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3320 | Abdominoperineal resection of rectum and anus | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L1880 | Repair of leaking aneurysm of arch of aorta | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| W8100 | Open excision of calcific deposit (eg shoulder, hip) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| Y3820 | Insertion of indwelling psoas catheter | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T1640 | Repair of congenital diaphragmatic hernia | Xmajor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0607 | Photodynamic therapy (PDT) to malignant lesion of skin, with artificial light source, four or more | Major | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| B3595 | Excision of mammary fistula | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L6230 | Reconstruction/bypass for popliteal aneurysm | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.1 | Investigations | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V5210 | Chemonucleosis (multiple levels) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C5910 | Iridocyclectomy | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3733 | Revision of total hip replacement (including insertion of reconstruction rings, plates, screws, etc., and/or impaction bone grafting to acetabulum and/or femur) - unilateral | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
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| 3.3 | Paraspinal injections | ||||
| A5200 | Epidural injection (cervical) | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
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| 2.5 | Vessels | ||||
| L3320 | Clipping of cerebral artery aneurysm | Complex | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5960 | Femoro-distal calf bypass using vein | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
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| 8.10 | Great Vessels | ||||
| L2190 | Replacement of graft of thoraco-abdominal aneurysm | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
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| 11.9 | Abdominal wall | ||||
| T2100 | Repair of recurrent inguinal hernia | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W6523 | Primary open reduction of dislocation of large joint | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K0930 | Closure of partial atrioventricular septal defect | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
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| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W6913 | Total synovectomy of large joint | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
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| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E5180 | Diagnostic bronchoscopy +/- biopsy | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
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| 16.10 | Knee | ||||
| W7580 | Open surgical stabilisation of patella, including soft tissue/tendon transfer or release, +/- application of cast (adult) | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
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| 12.1 | Kidney/renal pelvic | ||||
| M0300 | Open partial nephrectomy | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
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| 17.1 | Biopsy | ||||
| XR140 | Unilateral stereotactic core biopsy breast | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
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| 6.3 | Tongue | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
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| 16.9 | Hip, leg and pelvis | ||||
| W0702 | Excision of ectopic bone around a total hip replacement | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
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| 11.1 | Oesophagus | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
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| 4.3 | Lacrimal system | ||||
| C2542 | Dacryocysto-rhinostomy (endoscopic/laser assisted), including insertion and later removal of tube | Xmajor | |||
| 4.9 | Lens | ||||
| C7122 | Ultrasound phacoemulsification of cataract, with lens implant - unilateral (including topical or local anaesthetic) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W8650 | Therapeutic sub-talar arthroscopy additional to synovectomy to gain vision | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1581 | Laparoscopic colostomy and stoma formation (including revision) | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
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| 14.2 | Suspension | ||||
| M5100 | Combined abdominal and vaginal operations to support outlet of female bladder (including sling procedures)(including cystoscopy) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W1640 | Simple pelvic osteotomy and fixation eg Salter or Chiari osteotomies | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7510 | Thorascopic cervical sympathectomy | Xmajor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
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| 15.1 | Lesions of skin | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.11 | Liver | ||||
| XR576 | Biliary drainage with occluded stent in place | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2402 | Transthoracic fundoplication | Xmajor | |||
| 18 | Chemotherapy | ||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
|||||
| 18.0 | Chemotherapy | ||||
| X0004 | Clinical supervision and planning for delivery of chemotherapy And/Or Systemic Anti-Cancer Therapy for 1-28 Days | ||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| L8600 | Unilateral varicose vein injection sclerotherapy | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S7010 | Wedge excision or avulsion of nail (including chemical ablation of nail bed) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| T7292 | Trigger point injection/Enthesis - more than one injection | Minor | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0881 | Excision of joint of toe with release of contracture and soft tissue correction | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B0900 | Operations on aberrant thyroid tissue (including excision/removal of retrosternal goitre) | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6582 | Adult cardiac catheterisation - radial access (including coronary arteriography/catheterisation of right/left side of heart/contrast radiology) - with pressure wire (including fractional flow reserve measurement) | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| T0910 | Open pleural biopsy as sole procedure | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3220 | Revision of gastro–jejunostomy | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1360 | Endoscopic balloon dilation frontal sinuplasty and bilateral | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| Q0230 | Cauterisation of lesion of cervix uteri (+/- loop diathermy, colposcopy or polypectomy) | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.9 | Thorax | ||||
| XR595 | Insertion of tracheal/bronchial metallic stent | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5080 | Repair of anal trauma | Intermediate | |||
| H5510 | Laying open of low anal fistula (fistulotomy) (including sigmoidoscopy) | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2380 | Anterior (+/- posterior) colporrhaphy with vaginal hysterectomy (including primary repair of enterocele and cystoscopy) | Xmajor | |||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L1960 | Open infrarenal abdominal aortic aneurysm bifurcation graft | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W7872 | Arthroscopic arthrolysis of shoulder contracture +/- manipulation/injection | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S5710 | Debridement of wound (and surgical toilet) - up to 25cm² in area | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W7780 | Revision stabilisation of shoulder joint | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6532 | Holmium laser resection of prostate (HoLRP) (including cystoscopy) | Xmajor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| X1420 | Anterior exenteration of pelvis | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5910 | Needle biopsy of lung | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| B2890 | Ultrasound guided interstitial laser ablation of breast lesion | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| D2630 | Osseous labyrinthectomy | Xmajor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S1740 | Large myocutaneous (muscular/cutaneous) flap (9cm2 or more) including closure of secondary defect | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L2200 | Revision of prosthesis of abdominal aorta | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E5442 | Video-Assisted Thoracoscopic Surgery (Vats) Assisted Wedge Resection Of Lung | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2000 | Excision of lesion of vagina (e.g. warts and cysts) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5702 | Thoracotomy lung volume reduction - unilateral | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K1000 | Closure of defect of interatrial septum (secundum Atrial Septal Defect or Patent Foramen Ovale) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W5560 | OK (Outerbridge and Kashiwagi) procedure | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S3622 | Full thickness graft, trunk and limbs ? up to 9cm2 in area | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2080 | Unilateral replantation of ureter into bladder (including cystoscopy) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| T0710 | Decortication of pleura of lung | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2510 | Excision of ureterocele (with or without ureteric reimplantation) - unilateral | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1892 | Immediate repair of aortic dissection (ie within two weeks of happening) | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1080 | Laparoscopic pyeloplasty - unilateral | Complex | |||
| 12.3 | Bladder | ||||
| M4420 | Endoscopic extraction of calculus of bladder (including cystoscopy) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| XR270 | Angioplasty with insertion of metallic stent-graft | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3364 | Laparoscopic anterior resection - high (i.e. colorectal anastomosis above the peritoneal reflection) | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H4680 | Repair of faecal fistula | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W6200 | Total fusion of all joints of wrist with or without graft and with or without internal fixation | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5250 | Circular stapling haemorrhoidectomy | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7190 | Extracapsular cataract extraction with implant - bilateral | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H4122 | Transanal endoscopic mircosurgery | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M5520 | Implantation of artificial urinary sphincter at bladder neck and/or removal (including cystoscopy) | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0610 | Biopsy of lesion of orbit | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J3000 | Anastomosis of common bile duct | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5780 | Ablation of accessory pathway or selected modification of AV node (including mapping) | Complex | |||
| K6520 | Paediatric cardiac catheterisation | Major | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8680 | Bilateral varicose vein injection sclerotherapy | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2220 | Partial glossectomy for malignancy | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6010 | Cardiac pacemaker system introduced through vein (dual chamber) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M1910 | Construction of ileal conduit including ureteric implantation | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3362 | Primary posterior fusion with instrumentation +/- decompression +/- discectomy (including Graf stabilisation and all fusion approaches) (lumbar region) including spinal cord monitoring | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q3800 | Laparoscopy and therapeutic procedures (including laser, diathermy and destruction e.g. endometriosis, adhesiolysis, tubal and ovarian surgery, +/-ureterolysis) | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| Q1030 | Dilatation of cervix uteri and curettage of uterus including polypectomy and diathermy of cervix | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W1913 | Pinning for bilateral slipped upper femoral epiphysis | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.3 | Meninges | ||||
| A3830 | Operation for arachnoidal cyst | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2600 | Replacement or repair of aortic valve | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2430 | Transabdominal anti-reflux operations | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22022 | Recording and reporting on electromyography and nerve conduction studies (EMG); CTS (Bilateral upper limb only) or peripheral neuropathy | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q1703 | Impedance controlled bipolar radiofrequency ablation for menorrhagia including hysteroscopy | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S1700 | Distant flap ? delay/division/inset | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7085 | Sacral nerve stimulation for faecal/urinary incontinence or constipation | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1090 | Robotic assisted pyeloplasty - unilateral | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H4200 | Perineal repair of prolapse of rectum | Major | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B2780 | Simple mastectomy (including axillary node biopsy) ? unilateral | Major | |||
| 7.4 | Other | ||||
| B3440 | Microdochotomy | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| XR121 | Unilateral image guided vacuum assisted excision of breast lesion (with biopsy) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0440 | Division of adhesions of turbinate of nose (and bilateral) | Minor | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W7980 | Metatarsal Osteotomy (Eg Scarf) For Hallux Valgus, +/- Internal Fixation +/- Soft Tissue Correction - Bilateral | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M5250 | Needle suspension of bladder neck (including cystoscopy) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T1500 | Repair of rupture of diaphragm | complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W4420 | Complex total replacement of ankle (ie including custom prosthesis, wedges, internal fixation of fractures) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E5591 | Video-Assisted Thoracoscopic Surgery (VATS) Assisted Bullectomy - Bilateral +/- Pleurodesis | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| T7603 | Microvascular free tissue transfer (as sole procedure including closure of secondary defect) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| T1032 | Thoracoscopy and drainage and chemical pleurodesis | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6110 | Excision of lesion of peripheral nerve (eg neurilemoma) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2012 | Laparoscopic repair of inguinal hernia - bilateral | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6230 | Laser iridotomy - Unilateral | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0510 | Excision of lesion of cranium | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| M8120 | Meatoplasty | Intermediate | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8580 | Block dissection of pelvic lymph nodes (as sole procedure) | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0651 | Removal of benign lesion on trunk or limbs less than 10 cm in diameter or on scalp less than 5cm in diameter (excluding lipoma) | Minor | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J2900 | Anastomosis of hepatic duct | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.7 | Sclera | ||||
| C5720 | Repair of scleral laceration | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| F0110 | Excision of vermilion border of lip and advance of mucosa of lip | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W7430 | Reconstruction of lateral collateral ligament complex | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2612 | Replacement of aortic valve with homograft or stentless porcine | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0220 | Total oesophagectomy and interposition of intestine | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| T6723 | Revision Of Lengthening Of Achilles Tendon | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0400 | Open excision of lesion of oesophagus | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6120 | Trabecular stent bypass microsurgery for open-angle glaucoma (including topical or local anaesthetic) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3880 | Stab cystostomy | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S4183 | Debridement and primary suture of wound with involvement of deeper tissue - Trunk and Limbs | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1742 | Lateral rhinotomy into sinuses | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B0850 | Isthmectomy of thyroid gland | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N2200 | Operation(s) on seminal vesicle | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| 16.12 | External fixation/traction | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2200 | Primary repair of femoral hernia | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 16.10 | Knee | ||||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L4600 | Other open operations on other visceral branch of abdominal aorta | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H4180 | Full or partial thickness rectal biopsy | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W5050 | Reverse polarity arthroplasty of shoulder | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L6800 | Repair of limb artery | Xmajor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J6300 | Open examination of pancreas | Major | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8610 | Biopsy/sampling of cervical lymph nodes | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9240 | Examination/ manipulation of joint under general anaesthetic +/- injection +/- arthrogram (as sole procedure) | Minor | |||
| 16.6 | Hand | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0500 | Bypass of oesophagus | Xmajor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G6500 | Diagnostic eosophago-gastro-duodenoscopy (OGD) includes forceps biopsy, biopsy urease test and dye spray | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T6220 | Excision of bursa | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0310 | Submucous resection of nasal septum | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6940 | Irrigation/aspiration of anterior chamber | Minor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A1440 | Irrigation of cerebroventricular shunt | Minor | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8780 | Ligation/stripping of long and short saphenous veins (including local excision/multiple phlebectomy) bilateral | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M6480 | Operation to support outlet of male bladder (including sling procedures) (including cystoscopy) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G5810 | Excision of jejunum | Major | |||
| 11.7 | Other organs (mainly digestive) | ||||
| L8110 | Creation of peritoneovenous shunt (Levine/Denver) | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G1900 | Rigid oesophagoscopy including any biopsy, laser or diathermy destruction of lesions | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| 4.10 | Vitreous | ||||
| C7923 | Intravitreal injection of pharmaceutical for neovascular age related macular degeneration | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| L2710 | Endovascular aneurysm repair (EVAR) of infrarenal aorta | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1470 | Median drainage of frontal sinus (modified Lothrop procedure) and bilateral | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0830 | Vaginal hysterectomy with laparoscopic assistance +/- ureterolysis | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K4920 | Percutaneous transluminal angioplasty of coronary artery(ies) for chronic total occlusions (CTO), +/- insertion of stent | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9043 | Injections of viscosupplement into joints - bilateral | Minor | |||
| 16.6 | Hand | ||||
| W0514 | Prosthetic surface arthroplasty of interphalanageal/metacarpo-phalangeal joint – single joint (both cemented and uncemented) | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| H2510 | Rigid sigmoidoscopy including proctoscopy and biopsy | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S4182 | Debridement and primary suture of wound with involvement of deeper tissue - Head and Neck | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A4400 | Partial excision of spinal cord | Complex | |||
| 3.3 | Paraspinal injections | ||||
| 25160 | Trigeminal ganglion radiofrequency lesion (under X-ray control) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K4610 | Minimally invasive direct coronary artery bypass (MIDCAB) including harvesting of graft | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7451 | 2 stage revision anterior cruciate ligament reconstruction - first stage | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0212 | Excision of lesion of orbit - anterior approach | Major | |||
| 4.5 | Conjuctiva | ||||
| C4100 | Drainage of conjunctival cyst | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S4480 | Removal of foreign body in deeper tissue | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| 16.11 | Foot | ||||
| 16.13 | Amputation | ||||
| X0822 | Amputation of whole ray | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4900 | Open biopsy of lesion of spine where no other operative procedure on the spine is performed. | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| W2910 | Application of skeletal traction to bone | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1420 | Myringoplasty | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0462 | Complex procedure to mid foot or hind foot with autogenous bone graft (osteotomy/fusion +/- tendon transfers/fixation) | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| L0110 | Correction of truncus arteriosus | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0510 | Open pyeloplasty | Major | |||
| 12.6 | Genitalia | ||||
| N2610 | Total amputation of penis | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 16.6 | Hand | ||||
| T6750 | Primary repair of flexor of hand (excluding Zone II) | Intermediate | |||
| 16.10 | Knee | ||||
| W7440 | Allograft anterior cruciate ligament reconstruction +/- Meniscectomy | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E3681 | Stroboscopy of larynx | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.3 | Duodenum | ||||
| G5050 | Endoscopic submucosal dissection of duodenal lesions | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5770 | Ablation of arrhythmia in complex congenital heart disease (including mapping) | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| S4780 | Aspiration of subcutaneous haematoma | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W9018 | Percutaneous biopsy/ arthrography/ aspiration in assessment of total hip replacement | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6711 | Cubital tunnel release (open) bilateral (without transposition) | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S4720 | Drainage of lesion of skin (including abscess) | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0330 | Biopsy of of septum of nose | Minor | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| B2830 | Re-excision of lesion of breast if resection margins are not clear (as sole procedure) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L6300 | Transluminal procedures on femoral artery | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J3300 | Incision of bile duct (including exploration for calculus removal) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2540 | Posterior excision of disc prolapse (including microdiscectomy +/- decompression) - lumbar region (1 or 2 levels) | Xmajor | |||
| 3.6 | Peripheral nerves | ||||
| A7010 | Implantation of neurostimulator into peripheral nerve | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T5900 | Excision of ganglion | Intermediate | |||
| 16.12 | External fixation/traction | ||||
| W3030 | Removal of external fixation from bone | Minor | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G8083 | Therapeutic oesophago-gastro-duodenoscopy (OGD) and immediate colonoscopy includes forceps biopsies, biopsy test and dye spray (as sole procedure) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5810 | Diagnostic intracardiac electrophysiological study including characterisation of intracardiac conduction and any testing of anti-arrhythmic drug efficacy by programmed stimulation | Major | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T9000 | Sentinel node mapping and sampling with blue dye or radioactive probe for breast cancer | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6030 | Replacement of generator for intravenous cardiac pacemaker system (without lead change) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1220 | Fine needle aspiration of thyroid gland | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6400 | Repair of peripheral nerve | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| S1500 | Biopsy of skin or subcutaneous tissue | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22028 | Inpatient Sleep study (polysomnography) including reporting | Minor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W6912 | Total synovectomy of small joint | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| Q0100 | Amputation of cervix uteri | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6752 | Primary repair of flexor of hand in Zone II | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR950 | Occlusion of fistula under imaging control | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3714 | Total hip replacement, with or without cement, after excision arthroplasty or arthrodesis, including conversion of hemiarthroplasty or revision of other previous hip surgery which involved internal fixation | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| E6100 | Open resection of invasive mediastinal tumour | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.1 | Investigations | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T5230 | Excision plantar fibroma | Intermediate | |||
| 16.4 | Nerves | ||||
| A6302 | Graft to major nerve | Xmajor | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8510 | Radical dissection of cervical lymph nodes | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2590 | Revision of anti-reflux procedures | Complex | |||
| 18 | Chemotherapy | ||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
|||||
| 18.0 | Chemotherapy | ||||
| X0002 | Clinical supervision and planning for delivery of chemotherapy And/Or Systemic Anti-Cancer Therapy For 1-14 Days | ||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8580 | Operations for recurrent varicose veins with re-exploration of groin and/or popliteal fossa - bilateral | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| M5250 | Needle suspension of bladder neck (including cystoscopy) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22011 | Recording and reporting on evoked potential study | Minor | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| R1820 | Caesarean delivery | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W3040 | Application of Ilizarov frame for secondary non-union/mal-union including osteotomy | Complex | |||
| 16.12 | External fixation/traction | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| Y3800 | Insertion of indwelling axillary catheter | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W1800 | Drainage/debridement of bone(s), including sequestectomy for osteomyelitis | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0604 | Secondary excision of malignant lesion - head and neck | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7510 | Secondary insertion of lens implant | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2902 | Revisional anterior discectomy (cervical region) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| S5730 | Surgical toilet and debridement of deep wound, including traumatic or post-operative aetiology | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| 9 | Vascular system | ||||
| 9.1 | Head and neck | ||||
| L2950 | Carotid endarterectomy | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0230 | Septorhinoplasty including graft/implant following trauma or excision of tumour (including attention to turbinates) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3720 | Repair of vesicocolic fistula | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7620 | Thoracic sympathectomy therapeutic (neurolytic under X-ray control) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1900 | Anastomosis of gall bladder (to another viscus) | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0702 | Aural toilet (including microsuction and/or suction of exteriorised mastoid cavity) including bilateral | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| C4350 | Exploration of conjunctiva (including removal of foreign body) | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1513 | Correction of lower lid ectropion with graft/flap | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1083 | Hemi-maxillectomy for malignancy | Xmajor | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8620 | Ultrasound-guided foam Sclerotherapy for varicose vein(s) unilateral | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| V0383 | Lateral petrosectomy (for tumour) | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W8110 | Arthroscopic excision of calcific deposits from shoulder | Major | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8640 | Sampling of internal mammary lymph nodes | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.1 | Investigations | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0510 | Total excision of colon and ileorectal anastomosis | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0730 | Repair of congenital oesophageal atresia (with or without fistula) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7583 | Repair of patellar/quadricep tendon | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2543 | Revision of posterior excision of disc prolapse with undercutting facetectomy (lumbar region) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T4610 | Paracentesis abdominis for ascites | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6015 | Implantation of biventricular pacemaker | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4991 | Therapeutic Panendoscopy +/- excision biopsy, excision or destruction of lesions | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H2220 | Endoscopic ultrasound for tumour staging, including diagnostic endoscopy | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2613 | Revision of aortic valve replacement | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0432 | Isolated Subtalar Fusion Or Midfoot Fusion With Autogenous Graft | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2910 | Total laryngectomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W6018 | Ankle arthrodesis – revision, including converstion from total ankle replacement | Intermediate | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| R2120 | Forceps cephalic delivery | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0940 | Percutaneous nephrolithotomy (including cystoscopy and retrograde catheterisation) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K1690 | Non-surgical reduction of myocardial septum (e.g. alcohol septal ablation) | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C5920 | Surgical Iridectomy +/- Biopsy | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22004 | 24 hour ambulatory Electroencephalography (EEG) (Including reporting) | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4840 | Dilatation of tracheal stricture including insertion of stent | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6530 | Carpal tunnel release (endoscopic) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6570 | Carpal tunnel release (endoscopic) - Bilateral | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2110 | Partial removal of vaginal mesh/tape with reconstruction of vagina and or/uretha, including cystoscopy and/or proctoscopy [fees on application] | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9033 | Injection of viscosupplement into joint with image guidance - bilateral | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| BT251 | Planning for insertion and removal of radioactive agent (brachytherapy) into rectal tumour | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.7 | Sclera | ||||
| C5730 | Scleral graft | Major | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9112 | Surgical insertion of central venous dialysis line | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| C2550 | Lacrimal intubation (as sole procedure) | Intermediate | |||
| 4.4 | Muscles | ||||
| C3113 | Surgical correction of squint - bilateral | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1000 | Therapeutic endoscopic operations on kidney (including cystoscopy and retrograde catheterisation) | Major | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| B3592 | Micropigmentation (tattooing) of nipple areola complex | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| C2650 | Probing of nasolacrimal system with/without syringing and/or irrigation | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4400 | Excision of parotid gland (other than F4410/F4430) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0740 | Open hepatectomy and ablation | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1512 | Correction of lower lid ectropion without graft/flap | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W5722 | Excision reconstruction of small joint | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2400 | Transthoracic fundoplication and gastroplasty | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1240 | Pulmonary embolectomy | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.10 | Vitreous | ||||
| C7982 | Pars plana vitrectomy with internal tamponade, scleral buckling and retinopexy with dissection or excision of epiretinal membrane/macular surgery | Complex | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| T9020 | Sentinel node mapping and sampling with blue dye and radioactive probe for breast cancer | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.3 | Duodenum | ||||
| G5100 | Bypass of duodenum | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| C4010 | Mucosal graft to conjunctiva | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H4190 | Therapeutic High Resolution Anoscopy (HRA) in symptomatic patients (+/- biopsy or ablation of lesion of anus) | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B0820 | Bilateral subtotal thyroidectomy | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3580 | Laparoscopic ventral rectopexy not requiring mesh | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| A7560 | VATS sympathectomy - unilateral | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0750 | Laparoscopic right hemicolectomy +/- stoma | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5430 | Pulmonary lobectomy including segmental resection | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q1800 | Hysteroscopy (including biopsy, dilatation, curettage and resection of polyp(s) +/- Mirena coil insertion) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.11 | Liver | ||||
| XR570 | Percutaneous insertion of plastic biliary endoprosthesis | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.3 | Meninges | ||||
| A4110 | Evacuation of subdural haematoma or abscess | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| X2280 | Manipulation of hip and casting (as sole procedure) | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1523 | Correction of entropion - upper lid, including graft/flap | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2510 | Repair of vesicovaginal fistula (including cystoscopy) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T0810 | Resection of rib and open drainage of pleural cavity | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| XR142 | Bilateral stereotactic core biopsy of breasts | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2650 | Suture of tongue (as sole procedure) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5100 | Haemorrhoidectomy (including sigmoidoscopy) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6740 | Cubital tunnel release (endoscopic) (without transposition) | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0890 | Vaginal hysterectomy including salpingo-oophorectomy (including laparoscopically assisted) +/- ureterolysis | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A4900 | Repair of spinal myelomeningocele | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6180 | Excision of lesion of major nerve | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2030 | Arthroplasty of temporomandibular bone joint - unilateral | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5704 | Thoracotomy bullectomy - unilateral +/- pleurodesis in presence of emphysema | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| T6780 | Primary repair of Achilles tendon | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A3000 | Repair of cranial nerve (intracranial) | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F5610 | Manipulative removal of calculus from parotid duct | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| XR280 | Insertion of aortic metallic stent-graft | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0940 | Photodynamic therapy (PDT), with artificial light source, to non malignant lesions of skin | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| A2730 | Highly selective vagotomy | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2970 | Sub-total laryngectomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| 16.10 | Knee | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.7 | Sclera | ||||
| C6181 | Laser suture lysis (including topical or local anaesthetic) | ||||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L1992 | Delayed repair of aortic dissection (ie more than two weeks after happening) | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1280 | Ultrasound guided radiofrequency ablation of benign thyroid nodule | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0390 | Extracorporeal septoplasty | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V5003 | Manipulation of spine without GA/IV sedation (as sole procedure) | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M5222 | Laparoscopic colposuspension | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
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| 17.13 | Other | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1910 | Reconstruction of jaw (non-vascularised reconstruction) | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| T1240 | Insertion of tube drain into pleural cavity | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2720 | Laparoscopic repair of incisional hernia requiring mesh | Intermediate | |||
| 9 | Vascular system | ||||
| 9.1 | Head and neck | ||||
| L3730 | Endarterectomy and patch repair of subclavian artery | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2980 | Combined anterior and posterior fusion of cervical spine | Complex | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H6260 | Proctoscopy (+/- Biopsy) | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W4230 | Revision of total replacement of knee joint | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4640 | Fine needle aspiration of parotid gland | Minor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| W9282 | Joint fluid examination (eg polarising microscopy) performed by consultant including aspiration of fluid | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G2120 | High resolution oesophageal manometry | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1041 | Hepatic venous wedge pressure (HVWP) | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0652 | Removal of benign lesion on trunk or limbs greater than 10 cm in diameter or on scalp greater than 5 cm in diameter (excluding lipoma) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3721 | Posterior fusion +/- instrumentation - cervical region (3 or more levels) Including Spinal Cord Monitoring | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W1648 | Osteotomy/transfer of greater trochanter in isolation | Xmajor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3600 | Enlargement of bladder (including cystoscopy) | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.5 | Practitioner and Therapist fees | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.10 | Vitreous | ||||
| C7924 | Intravitreal injection of pharmaceutical for central retinal vein occlusion | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3400 | Open excision of lesion of rectum and colon | Major | |||
| H4480 | Dilation of stricture of rectum | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G2710 | Total gastrectomy and excision of surrounding tissue | Complex | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7410 | Creation of arteriovenous shunt (synthetic graft) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E2320 | Open operation(s) on pharyngeal pouch | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W5040 | Replacement of elbow and shoulder (single operation) | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4122 | Anterior correction of idiopathic juvenile kyphosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | |||
| 18 | Chemotherapy | ||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
|||||
| 18.0 | Chemotherapy | ||||
| A5480 | Intrathecal chemotherapy | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6513 | Adult cardiac catheterisation - radial access (including coronary arteriography/ catheterisation of right/left side of heart/contrast radiology) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2201 | Posterior decompression +/- foraminotomy - cervical region (3 or more levels) | Complex | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.2 | Stem Cell | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q1701 | Laparoscopic excision of endometriosis, +/-ureterolysis | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0400 | Biopsy of lesion of tissue of brain (including via a burr hole or stealth guided) | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6110 | Excision of lesion of peripheral nerve (eg neurilemoma) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6070 | Implant of temporary pacing electrode (as sole procedure) | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2012 | Replantation of ureter into bowel (including bilateral) | Xmajor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q2233 | Open oophorectomy and salipingectomy, +/- biopsy e.g. omentum, peritoneum, lymph node (as sole procedure) - bilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7430 | Reconstruction of lateral collateral ligament complex | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N0920 | Orchidopexy | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D2030 | Removal of Grommets | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1370 | Endoscopic balloon dilation maxillary sinuplasty and bilateral | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6762 | Photoselective vaporisation of prostate (KTP Laser PVP) (including cystoscopy) | Xmajor | |||
| 12.5 | Prostate | ||||
| 12.6 | Genitalia | ||||
| N1510 | Bilateral epididymectomy | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3345 | Mobilisation of the lumbar/thoracic vessels to provide spinal surgical access (by vascular surgeon) as sole procedure | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S1900 | Distant pedicle flap ? elevation including transfer (including closure/grafting to secondary defect) | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2922 | Partial reconstruction of breast using pedicled perforator flap (eg. Lateral Intercostal Artery Perforator (LICAP) or Thoraco-Dorsal Artery Perforator (TDAP) including delayed reconstruction) | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2501 | Primary posterior fusion +/- decompression +/- discectomy - lumbar region (3 or more levels) including spinal cord monitoring | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| XR160 | Percutaneous image guided fine needle aspiration(s) (FNA) - Unilateral | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7332 | Closure of fistula of urethra after hypospadias | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0653 | Removal of benign lesion in muscle or deeper tissue (excluding lipoma) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W4200 | Complex primary total knee replacement (ie including bone graft, augmentation or osteotomy) | Complex | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| B3594 | Plastic procedures on nipple | Intermediate | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B2742 | Modified radical mastectomy including lymph node sampling | Major | |||
| 7.3 | Reconstruction | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25110 | Coeliac plexus block, splanchnic nerve block, hypogastric block - therapeutic +/- Image Guidance | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| 16.7 | Shoulder | ||||
| A7340 | Exploration and grafting of brachial plexus | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6530 | Carpal tunnel release (endoscopic) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0250 | Nephrectomy - unilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0282 | Total excision of trapezium | Xmajor | |||
| 16.9 | Hip, leg and pelvis | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5500 | Total pancreatectomy and excision of surrounding tissue | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6009 | Planning and preparation for the delivery of Selective Internal Radiotherapy (SIRT) | ||||
| X6010 | Planning and preparation for the delivery of 3D conformal radiotherapy (3DCRT) | ||||
| BT282 | Insertion and removal of radioactive agent (brachytherapy) into the vagina | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G8085 | THERAPEUTIC OESOPHAGO-GASTRO-DUODENOS (OGD)&IMMEDIATE FLEXIBLE SIGMOIDOSCOPY | INT | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5754 | Nerve Root Block +/- Image Guidance (Including Bilateral) Thoracic | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0120 | Enucleation/evisceration of eyeball | Major | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5400 | transluminal operations on iliac artery | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2000 | Primary repair of inguinal hernia | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0260 | Endoscopically assisted oesophagectomy | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7500 | Excision of diverticulum of urethra (including cystoscopy) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W8850 | Diagnostic subtalar arthroscopy including synovectomy to gain vision (as sole procedure) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2546 | Posterior excision of disc prolapse with undercutting facetectomy +/- decompression - lumbar region (3 or more levels) | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7341 | YAG (Yttrium Aluminium Garnett) Laser Photodisruption Of Posterior Capsule Of Lens (Including Laser Capsulotomy) - Bilateral | Intermediate | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.2 | Stem Cell | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6111 | Laser trabeculoplasty (including topical or local anaesthetic) - unilateral | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A7013 | Placement of tined lead neurostimulator not at time of permanent implant | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| 16.10 | Knee | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N3210 | Biopsy of lesion of penis | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.8 | Spine | ||||
| XR510 | Fluoroscopically guided discectomy (including laser) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| AA489 | Transtympanic chemical labrynthectomy | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N3030 | Circumcision | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W5200 | Unicompartmental Knee Replacement - Unilateral | Xmajor | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| T9030 | Intraoperative sentinel node mapping, using One Step Nucleic Acid Amplification (OSNA), for breast cancer | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6514 | Adult cardiac catheterisation - brachial access (including coronary arteriography/ catheterisation of right/left side of heart/contrast radiology) | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0282 | Laparoscopic nephroureterectomy - unilateral | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.7 | Teeth | ||||
| F0911 | Coronectomy | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.9 | Thorax | ||||
| XR600 | Insertion of oesophageal metallic stent under imaging control | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1240 | Exploration of facial nerve, mastoid segment, facial nerve | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| X4810 | Change of cast without general anaesthetic (as sole procedure) | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
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| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4010 | Posterior correction of idiopathic juvenile kyphosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1380 | Arthroscopic femoro-acetabular surgery for hip impingement syndrome, including labral repair and osteochondroplasty | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1150 | Graft of skin to canthus | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W8193 | Arthroscopic subacromial decompression | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2402 | Transthoracic fundoplication | Xmajor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6511 | Adult cardiac catheterisation - femoral access (including coronary arteriography/ catheterisation of right/left side of heart/contrast radiology) | Intermediate | |||
| K6115 | Insertion of an implantable cardioverter defibrillator with subcutaneous leads (subcutaneous ICD) | Complex | |||
| K5020 | Coronary angiography proceeding to angioplasty on the same day, +/- insertion of stent | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0710 | Radical hysterectomy and lymphadenectomy (Wertheim's) +/- ureterolysis | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8782 | Flexible arthroscopy, +/- biopsy (as sole procedure) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C4690 | Implantation of synthetic corneal rings for keratoconus (including INTACS) | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| M5280 | Revision retropubic suspension of neck of bladder (including colposuspension and cystoscopy) | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| Q1280 | Introduction of a Mirena coil | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T5202 | Dupuytren’s fasciectomy palm only | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8150 | Arthrotomy of large joint, including removal of loose body from joint | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2340 | Transabdominal repair of diagphragmatic hernia (excluding hiatus hernia) | Complex | |||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5520 | Open excision of lesion of lung | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T1910 | Simple excision of inguinal hernial sac (herniotomy) ? bilateral | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| F3070 | Suture of palate | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6980 | Removal of foreign body from anterior chamber | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| B2233 | Laparoscopic Adrenalectomy - Unilateral | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.11 | Other | ||||
| A2780 | Vagotomy and pyloroplasty | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S3623 | Full thickness graft, trunk and limbs ? each additional 25cm2 in area | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2282 | Prosthetic intervertebral disc replacement - cervical region (1 or 2 levels) +/- Spinal Cord Monitoring | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0941 | Percutaneous nephrolithotomy (including cystoscopy and retrograde catheterisation) (involving two specialties) (we will pay this fee per specialty) | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| F2621 | Frenotomy /frenectomy of tongue under local anaesthetic (as sole procedure) | ||||
| 18 | Chemotherapy | ||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
|||||
| 18.0 | Chemotherapy | ||||
| X0100 | Electrochemotherapy for malignant lesions | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X1110 | Amputation of toe | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A1250 | Creation of subcutaneous cerebrospinal fluid reservoir | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0640 | Closure of bypass of oesophagus | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5700 | Thoractomy lung volume reduction - bilateral | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H4130 | Perianal excision of lesion of rectum (including sigmoidoscopy) | Intermediate | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2986 | Reconstruction of breast using deep inferior epigastric perforator flap (DIEP) (including delayed reconstruction) - unilateral (Single Flap) | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.10 | Gastrointestinal | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6982 | Tenolysis of flexor tendon of hand | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5050 | Coronary angioplasty following angiography with intravascular ultrasound on the same day, +/- insertion of stent | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W0610 | Total excision of cervical rib | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4452 | Balloon kyphoplasty - two level | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A1430 | Removal of cerebroventricular shunt | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M1820 | Excision of segment of ureter | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7360 | Simple urethroplasty, eg primary repair, segment, anterior urethra (including cystoscopy) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5230 | Epidurogram +/- epidural injection | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C5180 | Corneal scraping for culture | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1300 | Percutaneous biopsy of lesion of liver | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E5932 | VATS lung biopsy | Intermediate | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0383 | Lateral petrosectomy (for tumour) | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3340 | Primary anterior discectomy, decompression and anterior fusion +/- instrumentation lumbar region (1 or 2 levels) including spinal cord monitoring | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| F0530 | Suture of lip (as sole procedure) | Minor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0130 | Surgery for craniostenosis (single suture) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B0860 | Partial thyroidectomy (not elsewhere classified) | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0200 | Partial hepatectomy (left hepatectomy or resection of up to three segments) +/- choleycystectomy | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6019 | Planning And Preparation For The Delivery Of MR Linac Adaptive Planned Radiotherapy | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7212 | Paediatric cataract involving lensectomy with lens implant unilateral | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5745 | Medial branch block injection(s) +/- image guidance (including bilateral) LUMBAR | Intermediate | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT210 | Oral introduction of liquid radioactive agent for malignant thyroid tumour ablation | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| C6180 | Bleb needling +/- antimetabolites (including topical or local anaesthetic) | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2621 | Frenotomy/frenectomy of tongue +/- local or topical anaesthetic (as sole procedure) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6051 | Aqueous shunt tube surgery for glaucoma (including topical or local anaesthetic) including donor patch - unilateral | Intermediate | |||
| C6720 | Laser treatment for glaucoma e.g. Cyclodiode | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2510 | Laparoscopic repair of parastomal hernia requiring mesh | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4081 | Anterolateral access with instrumentation +/- decompression +/- duscectomy (including graf stabilisation and all fusion approaches) -lumbar region (3 or more levels) | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| X1430 | Posterior exenteration of pelvis | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0122 | Enucleation/evisceration of eyeball (with implant) | Major | |||
| 4.9 | Lens | ||||
| C7110 | Extracapsular cataract extraction without implant - unilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W4210 | Total Prosthetic Replacement Of Knee Joint +/- Cement +/- Patella Resurfacing - Unilateral | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| A5410 | Epidural blood patch | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W6016 | Open Ankle arthrodesis with autogenous graft | Intermediate | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5924 | Femoro-popliteal bypass using vein cuff/patch | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6590 | Coronary angiography including intravascular ultrasound | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0303 | Robotic assisted partial nephrectomy - unilateral | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.7 | Head and neck | ||||
| XR315 | Endoluminal stone extraction from salivary duct under imaging control | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6105 | Insertion of dual chamber implantable cardioverter defibrillator (ICD) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0900 | Diagnostic laparoscopy (including any biopsy) | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G4430 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with dilatation | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J6200 | Incision of pancreas | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L2600 | Percutaneous transluminal balloon operations on aorta | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W8194 | Arthroscopic sub-acromial decompression and excision of distal clavicle (including arthroscopic procedures in glenohumeral joint) | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X7019 | Delivery of a Fraction MR Linac Adaptive Planned Radiotherapy, Including Image Guidance | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7210 | Paediatric cataract involving lensectomy without lens implant unilateral | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2784 | Minimally Invasive Component Separation Technique (CST) Not Requiring Mesh | Extra Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| W6960 | Needle biopsy of synovium | Minor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G4440 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with insertion of percutaneous endoscopic gastrostomy/percutaneous endoscopic jejunostomy | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0620 | Drainage of orbit | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1530 | Myringotomy (and bilateral) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.3 | Trachea | ||||
| E4030 | Tracheoplasty | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T7972 | Exploration and repair of groin disruption including repair of muscle fascia and tendons (Gilmore's Groin Repair) | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2340 | Repair of enterocele (+/- posterior repair colporrhaphy) (as sole procedure) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1992 | Delayed repair of aortic dissection (ie more than two weeks after happening) | Complex | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8722 | Selective dissection of cervical lymph nodes, levels 1 to 4 | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W8830 | Diagnostic arthroscopic examination of wrist joint, with or without biopsy (as sole procedure) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T9610 | Excision of cystic hygroma | Major | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| R2810 | Curettage of delivered uterus | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0923 | Laser destruction of lesion(s) of skin - over 25cm² in area | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.5 | Vulva/labia | ||||
| P0610 | Laser destruction of lesion of vulva | Minor | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7492 | Lateral Release | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K1800 | Placement of valve to cardiac conduit | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W0630 | Patellectomy | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1800 | Cholecystectomy (including mini-cholecystectomy) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6730 | Drainage of prostatic abscess | Intermediate | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W3652 | Trephine biopsy of bone marrow | Minor | |||
| 16.7 | Shoulder | ||||
| W5630 | Secondary repair of acromioclavicular or sternoclavicular joint +/– internal fixation | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| E3180 | Thyroplasty (Isshiki type 1) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5720 | Ablation of AV nodal re-entry tachycardia (including mapping) | Complex | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8542 | Radiofrequency ablation of single venous trunk +/- phlebectomies - unilateral | Intermediate | |||
| L8543 | Radiofrequency ablation of single venous trunk +/- phlebectomies - bilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6740 | Cubital tunnel release (endoscopic) (without transposition) | Intermediate | |||
| 16.9 | Hip, leg and pelvis | ||||
| W3741 | Proximal Femoral Replacement | Complex | |||
| 16.11 | Foot | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G6710 | Intubation of jejunum for decompression of intestine (without laparotomy) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5000 | Percutaneous examination of bile duct | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.10 | Gastrointestinal | ||||
| XR585 | Percutaneous gastrostomy (as sole procedure) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3730 | Trans oral surgery including posterior fixation | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E2010 | Adenoidectomy | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5760 | Ablation of left atrial fibrillation by isolation of the pulmonary veins left/right (RFA/CRYO/Laser) (including mapping) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2620 | Repair of recurrent incisional hernia requiring mesh | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2951 | Anterior discectomy, decompression and fusion (including bone grafting) - cervical region (3 or more levels) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6584 | Adult cardiac catheterisation - femoral access (including coronary arteriography/catheterisation of right/left side of heart/contrast radiology) - with pressure wire (including fractional flow reserve measurement) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4713 | Bladder instillation as sole procedure | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G1470 | Fibreoptic endoscopic photodynamic therapy (PDT) of lesion of oesophagus | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2901 | Anterior discectomy - cervical region (3 or more levels) | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7313 | Repair of penile shaft hypospadias | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| XR110 | Ultrasound guided biopsy(ies) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T3610 | Omental biopsy +/- an ascitic drain under image guidance | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1730 | Extra-oral fixation of mandible | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1300 | Bypass of colon | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6052 | Aqueous shunt tube surgery for glaucome (including topical or local anaesthetic) including donor patch - bilateral | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W7718 | Primary arthroscopic shoulder stabilisation procedure (including labral/SLAP/tendon repair) | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M7071 | TRANSURETHRAL WATER JET ABLATION FOR LOWER URINARY TRACT SYMPTOMS CAUSED BY BENIGN PROSTATIC HYPERPLASIA | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G6080 | Laparoscopic small bowel resection +/- stoma | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| T7982 | Arthroscopic sub acromial decompression and rotator cuff repair (including arthroscopic procedures in glenohumeral joint) | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| Q2080 | Ventrosuspension of uterus (including laparoscopic) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3341 | Primary anterior discectomy, decompression and anterior fusion +/- instrumentation - lumbar region (3 or more levels) including spinal cord monitoring | Xmajor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G4370 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with elective banding of oesophageal varices | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6990 | Insertion Of Valve Into Anterior Chamber Of Eye *** Refer To Spine 178 *** | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4810 | Open biopsy of lesion of salivary gland | Minor | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L6000 | Endarterectomy of femoral artery | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6830 | Secondary or second repair of 1st stage reconstruction of flexor of hand | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| S4760 | Fine needle aspiration cytology | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8540 | Radiofrequency ablation of more than one venous trunk +/- phlebectomies - unilateral | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0251 | Nephrectomy - bilateral | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2680 | Revision anterior discectomy, decompression and anterior fusion +/- intrumentation (lumbar region) including spinal cord monitoring | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7312 | Repair of penile/perineal hypospadias | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W7720 | Minimally Invasive Sacrolliac Joint Stabilisation Surgery for Chronic Sacrolliac Pain Under Image Guidance | Complex | |||
| 16.6 | Hand | ||||
| 16.11 | Foot | ||||
| T6822 | Delayed or secondary repair of Achilles tendon with tendon or fascial graft | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5101 | Laser haemorrhoidectomy (including sigmoidoscopy) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR361 | Prostate Artery Embolisation | major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2161 | Therapeutic arthroscopic operation of temporomandibular joint +/- lysis and/or lavage -unilateral | intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6110 | Laser trabeculoplasty (including topical or local anaesthetic) ? bilateral | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7361 | Complex Urethroplasty, Eg Revision Surgery of the Anterior Urethra, Segment, Posterior Urethra, +/- Grafting (Including Cystoscopy) | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT260 | Planning for insertion and removal of radioactive agent (brachytherapy) into carcinoma of the oesophagus, bronchus or stomach | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S1750 | Large muscle flap (9cm2 or more) including skin graft and closure of secondary defect | Xmajor | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2819 | Mastectomy and immediate reconstruction of breast using expandable prosthesis and acellular dermal matrix (ADM) - bilateral | Extra Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT343 | Planning, insertion and removal of radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6910 | Reformation of anterior chamber | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.7 | Other nerve blocks | ||||
| A7352 | LOCAL ANAESTHETIC BLOCKADE OF NAMED MAJOR NERVE OR PLEXUS +/- IMAGE GUIDANCE (AS SOLE PROCEDURE) | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| C8240 | Photodynamic therapy to the retina (PDT) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W5780 | Excision arthroplasty of first metatarsophalangeal joint, (e.g. Keller, Bonney-Kessel procedures) including cheilectomy - bilateral | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0640 | Removal of foreign body from orbit | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2402 | Posterior decompression (thoracic region) Including Spinal Cord Monitoring | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T9030 | Intraoperative sentinel node mapping, using One Step Nucleic Acid Amplification (OSNA), for breast cancer | Intermediate | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2921 | Lumpectomy and immediate partial reconstruction of breast using pedicled perforator flap (eg. Lateral Intercostal Artery Perforator (LICAP) or Thoraco-Dorsal Artery Perforator (TDAP)) | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2930 | Biopsy of lesion of vagina | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9042 | Injection of viscosupplement into joint - unilateral | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| V5270 | Digital Subtraction myelogram/myelography (DSM) | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| C2510 | Canaliculo-dacryocysto-rhinostomy (including intubation) | Extra Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4850 | Therapeutic bronchoscopy for removal of foreign body | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2811 | Robotic assisted partial gastrectomy and excision of surrounding tissue | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3501 | Robotic assisted partial cystectomy with cystoscopy | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| Q0330 | Cone biopsy of cervix uteri and/or (+/- laser, colposcopy or polypectomy) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D2240 | Balloon dilatation of the eustachian tube | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6920 | Paracentesis of the eye | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6584 | Transrectal MRI - US Fusion Targeted Prostate Biopsy | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6750 | Cubital tunnel release (endoscopic) Bilateral (without transposition) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0330 | Fusion of first metatarsophalangeal joint - unilateral | Intermediate | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2780 | Open Component Separation Technique (CST) repair for Complex abdominal hernia with mesh | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V5230 | Discogram/diagnostic vertebral disc injection under X-ray control | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L0710 | Creation of shunt from subclavian artery to pulmonary artery | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.1 | Investigations | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W4902 | Shoulder hemiarthroplasty with reconstruction for fracture | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2640 | Repair of recurrent incisional hernia requiring removal of previously inserted mesh | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2996 | Reconstruction of breast using deep inferior epigastric perforator flap (DIEP) (including delayed reconstruction) - bilateral (single flap per breast) | Complex | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.2 | Stem Cell | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2151 | Arthrocentesis of temporomandibular joint - unilateral | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.10 | Vitreous | ||||
| C7940 | Intravitreal injection of pharmaceutical agent (not elsewhere classified) | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L2290 | Excision of infected aortic graft with bypass | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8180 | Arthrotomy of small joint, including removal of loose body from joint | Minor | |||
| 16.10 | Knee | ||||
| W1660 | Tibial osteotomy | Major | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.2 | Stem Cell | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1130 | Therapeutic ureterorenoscopy (+/- cystoscopy and insertion/removal of stent) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| V6080 | Percutaneous disc decmpression using coblation | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4512 | Examination of bladder using hexaminolevulinate blue-light fluorescence cystoscopy +/- resection of lesions | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6570 | Carpal tunnel release (endoscopic) - Bilateral | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4280 | Correction of adult degenerative or adult scoliosis including decompression +/- fusion (including spinal cord monitoring) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6581 | Coronary angioplasty following angiography with fractional flow study on the same day, +/- insertion of stent | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| T6520 | Tendon sheath injection of therapeutic substance including viscosupplement +/- image guidance | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1160 | Canthotomy | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6402 | Tendon transfer of hand – single | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1750 | Transnasal repair of leaking CSF (Including endoscopic) | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0512 | Simple reconstruction of socket (not including implant or graft) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B2743 | Modified radical mastectomy excluding lymph node sampling | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W4901 | Replacement of Proximal Humerus | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2227 | Laparoscopic repair of recurrent femoral hernia not requiring mesh - bilateral | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA518 | Penectomy (Removal Of Penis) +/- Scrotectomy For Gender Affirmation | Complex | |||
| GA202 | Excision Of Gonad From Abdomen For Gender Affirmation | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K4410 | Revision bypass for coronary artery(ies) (including harvesting of grafts) | Complex | |||
| 8.9 | Heart – cardiology | ||||
| K5280 | Map guided surgery for ventricular arrhythmias (including mapping) | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V0820 | Open reduction and fixation of fractured jaw | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| P2730 | Colposcopy (+/- biopsy, polypectomy or vulvoscopy) **REFER TO SPINE 555** | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W5520 | Revisional prosthetic replacement of elbow | Complex | |||
| 16.10 | Knee | ||||
| W7488 | Revision Posterior Cruciate Ligament Reconstruction Including Artificial Graft/Ligament | Extra Major | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.2 | Stem Cell | ||||
| U0170 | Umbilical Cord Blood Stem Cell Transplantation (UCBT) | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA403 | Laser Assisted Voice Adjustment For Gender Affirmation | Major | |||
| GA200 | Excision Of Mullerian Duct Remnant For Gender Affirmation | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT341 | Planning for insertion and removal of a radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | ||||
| BT212 | Insertion of low dose rate radioactive agent (brachytherapy) into prostate tumour | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4500 | Extracapsular Dissection of Parotid Tumour | Extra Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.0 | Abdomen (excluding urinary and reproductive organs) | ||||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| B3100 | Reduction mammoplasty - unilateral | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1818 | Reverse Ptosis Repair of Eyelid | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P1300 | Operations on female perineum | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| H5230 | Injection of sclerosing substance into haemorrhoids | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L2200 | Revision of prosthesis of abdominal aorta | Complex | |||
| 18 | Chemotherapy | ||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
|||||
| 18.0 | Chemotherapy | ||||
| X0100 | Electrochemotherapy for malignant lesions | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR915 | Insertion of central venous catheter-tunnelled (X-ray guided) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9030 | Injection(s) +/- aspiration, into joint, cyst, bursa with image guidance | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0780 | Radiofrequency thermocoagulation of liver with scalpel liver resection | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| C6180 | Bleb needling +/- antimetabolites (including topical or local anaesthetic) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| F4300 | Transoral laser microsurgery, including pharyngotomy, partial laryngectomy, partial glossectomy and/ or tracheostomy (as sole procedure) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E5594 | VATS debridement of empyema | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1440 | Excision of lesion of jaw | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2320 | Transthoracic repair of diaphragmatic hernia (acquired) | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T3980 | Excision of presacral tumour | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| BT212 | Insertion of low dose rate radioactive agent (brachytherapy) into prostate tumour | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W0640 | Total excision of sesamoid bone | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2581 | Minimally Invasive Mitral Valve Repair | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7211 | Paediatric Cataract Involving Lensectomy Without Lens Implant Bilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W8500 | Multiple arthroscopic operation on knee (including meniscectomy, chondroplasty, drilling or microfracture) - Unilateral | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E1920 | Partial pharyngectomy | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2990 | Open door laminoplasty of the cervical region (Hirobyashi) | Complex | |||
| V2900 | Anterior discectomy - cervical region (1 or 2 levels) | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5800 | Excision of lesion of pancreas | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W5550 | Excision of radial head (as sole procedure) | Major | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8582 | Operations for recurrent varicose veins without re-exploration of groin or popliteal fossa - bilateral | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3640 | Repair of bladder exstrophy | Complex | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.1 | Bone Marrow | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W7714 | Primary open or arthroscopic shoulder stabilisation pocedure (including labral/SLAP/tendon repair) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5040 | Rotoblation of coronary vessel(s) percutaneous transluminal rotational atherectomy (PCRS) +/- insertion of stent | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G2180 | Ambulatory 24h pH and impedance monitoring | ||||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR930 | BILATERAL INFERIOR PETROSAL SINUS SAMPLING | MAJOR | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W7761 | Repair of hip labral tear | Major | |||
| 16.10 | Knee | ||||
| W7530 | Repair of lateral collateral ligament complex | Major | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.1 | Bone Marrow | ||||
| 19.2 | Stem Cell | ||||
| U0100 | Autologous peripheral blood stem cell transplant | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W5800 | Conversion of a unicompartmental knee replacement to a total replacement of knee joint | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2999 | Reconstruction of breast using stacked deep inferior epigastric perforator flap (DIEP) (including delayed reconstruction) - unilateral (2 flaps) | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A1060 | Fiducial Placement | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3820 | Cystostomy and insertion of suprapubic tube into bladder (including cystoscopy) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9132 | Removal of tunnelled central venous catheter (Hickman line) | MInor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6231 | Laser Iridotomy - Bilateral | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6050 | Replacement implantable cardioverter defibrillator (ICD), without lead change | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0390 | Foramen magnum decompression | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0656 | Removal of lipoma | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| BT281 | Planning for insertion and removal of radioactive agent (brachytherapy) into the vagina | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1072 | Partial maxillectomy for benign tumour | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S4911 | Positional Surgical Adjustment To Skin Expander In Subcutaneous Tissue | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1130 | Correction of epicanthus | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0921 | Robotic assisted oesophagocardiomyotomy (Heller's) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2330 | Transabdominal repair of hiatus hernia | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0402 | Laparoscopic repair of liver (including therapeutic operations on liver) | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2520 | Repair of urethrovaginal fistula (including cystoscopy) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E3900 | Partial excision of trachea with reconstruction | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6410 | Repair of prolapsed iris | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0800 | Vaginal hysterectomy without laparoscopic assistance | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M7590 | Insertion of suburethral tape sling (e.g. TOT or TVT) +/- administration of local anaesthetic by operating surgeon (including cystoscopy) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W5310 | Total prosthetic replacement of wrist joint | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J6980 | Laparoscopic splenectomy | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6610 | Ciliary body ablation | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0820 | Excision of lesion of internal nose | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q3110 | Removal of products of conception from fallopian tube (ectopic pregnancy) including laparoscopically | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| C4050 | Suture of conjunctiva | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7200 | Urethrectomy | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| 16.10 | Knee | ||||
| W0633 | Prosthetic replacement of Patellofemoral joint - bilateral (as sole procedure) | Xmajor | |||
| 16.11 | Foot | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T0215 | Open surgical correction of pectus deformity of chest wall (or other congenital defect thereof) | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X7020 | Delivery of a fraction of Total body surface skin radiotherapy (TSEBT) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0323 | Revision of osteotomy/ies (eg Scarf and Akin) for hallux valgus correction +/- internal fixation +/- soft tissue correction - unilateral | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2818 | Mastectomy and immediate reconstruction of breast using expandable prosthesis and acellular dermal matrix (ADM) - unilateral | Extra Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| B3221 | Core biopsy of lesion of breast bilateral | Minor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5540 | Laser resection of lung metastases | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q2330 | Salpingectomy (including bilateral) (as sole procedure) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N3032 | Revision of circumcision | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2501 | Open repair of incisional hernia requiring mesh | Intermediate | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8880 | Endovenous mechanochemical ablation for varicose veins - unilateral | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.11 | Liver | ||||
| XR550 | Transarterial chemoembolization (TACE), +/- drug eluting bead (DEB) | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| S5322 | Injection of therapeutic substance into keloid scar | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6060 | Lead replacement for Pacemaker or implantable cardioverter defibrillator (ICD) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3490 | Endoscopic removal of percutaneous endoscopic gastrostomy (PEG) tube | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W0951 | Radical clearance of sarcoma of head and neck necessitating flap reconstruction | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0513 | Reconstruction of socket with either implant or graft | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7520 | Thoracic sympathectomy diagnostic (local anaesthetic under X-ray control) | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1690 | Mediastinal parathyroidectomy with sternotomy | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N0820 | Orchidopexy bilateral | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| G1400 | VATS excision lesion of oesophagus | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3335 | Endoscopic vaccum therapy for colorectal anastomotic leakage | Intermediate | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT252 | Insertion and removal of radioactive agent (brachytherapy) into rectal tumour | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C5131 | Ultraviolet irradiation of riboflavin for epithelium off cross linking of corneal collagen | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| L2780 | Endovascular aneurysm repair (EVAR) of suprarenal aorta, with insertion of fenestrated graft (three to four orifices) | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| X3520 | IV sedation administered by anaesthetist (as sole procedure) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H0480 | Abdominal revision of restorative proctocolectomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W3650 | Diagnostic aspiration and trephine biopsy of bone marrow, including analysis | Minor | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6018 | Planning and preparation for the delivery of Proton Beam Therapy (PBT) for non-ocular adult tumours | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0760 | Robotic assisted right hemicolectomy +/- stoma | Extra Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2572 | Percutaneous Vertebroplasty - 2 - 3 Levels | Major | |||
| 3.8 | Other procedures | ||||
| A5441 | CT-Guided Epidural Blood Patch (Two Level) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2008 | Laparoscopic repair of inguinal hernia not requiring mesh - unilateral | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.10 | Vitreous | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N1350 | Exploration of testis (including biopsy) | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0820 | Curettage/cryotherapy of lesions of skin including cauterisation - four or more | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| F3480 | Adenotonsillectomy (and bilateral) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| W7042 | Cannulation or decannulation for ECMO (Extracorporeal membrane oxygenation) | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3016 | Mastectomy and immediate reconstruction of breast using fat transfer | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A7340 | Exploration and grafting of brachial plexus | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T6580 | Tendon graft, or tendon transfer (as sole procedure, not otherwise specified) | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H6840 | Flexible pouchoscopy +/- biopsy and/or removal of polyp(s) | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| T7602 | Microvascular free tissue transfer (when added to other codes) including closure of secondary defect | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5540 | Seton placement for treatment of anal fistula | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V0722 | EMINECTOMY OF TEMPOROMANDIBULAR JOINT - BILATERAL | INTERMEDIATE | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0610 | Extended excision of right hemicolon | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E5435 | Robotic Assisted Navigation Bronchoscopy +/- Biopsy | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2014 | Laparoscopic repair of recurrent inguinal hernia not requiring mesh - unilateral | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3363 | Colectomy and colostomy and preservation of rectum | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7470 | Revision of anterior cruciate ligament reconstruction including autograft/allograft | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2940 | Partial laryngectomy | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5611 | LAPAROSCOPIC PANCREATODUODENECTOMY AND EXCISION OF SURROUNDING | complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2590 | Revision of anti-reflux procedures | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2414 | Laparoscopic repair of recurrent umbilical/paraumbilical hernia requiring mesh | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA504 | Phalloplasty Stage 2 (Using Non-Pedicelled Urethral Reconstruction) For Gender Affirmation (Including Cystoscopy) | Complex | |||
| GA524 | Vaginectomy (Removal Of Vagina) For Gender Affirmation | Complex | |||
| GA204 | Excision Of Gonad From Inguinal Canal For Gender Affirmation | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2215 | Laparoscopic repair of recurrent femoral hernia not requiring mesh - unilateral | Major | |||
| T2280 | Primary repair of strangulated femoral hernia | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| T6450 | Tenodesis of biceps tendon (as sole procedure) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| J9904 | Cytoreductive Surgery for Colorectal Peritoneal Carcinomatosis (7-8 distinct procedures) with intraperitoneal chemotherapy | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT251 | Planning for insertion and removal of radioactive agent (brachytherapy) into rectal tumour | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H6050 | Endoscopic Ablation for a Pilonidal Sinus | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| A7070 | Percutaneous electrical nerve stimulation (PENS) | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.5 | Vessels | ||||
| L3330 | Endovascular Insertion Of An Intrasaccular Wire-Mesh Blood-Flow Disruption Device For Intracranial Aneurysms | Extra Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3384 | Open Total Mesorectal Excision (TME) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6030 | Transection of peripheral nerve for neuroma | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5541 | Adjustment or removal of Seton under general anaesthetic | Minor | |||
| 9 | Vascular system | ||||
| 9.1 | Head and neck | ||||
| XR287 | Catheter cerebral venography and manometry | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E2501 | FIBRE OPTIC EXAMINATION OF THE PHARYNX +/- BIOPSY/REMOVAL OF FOREIGN BODY | MINOR | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G4480 | Therapeutic enteroscopy | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.11 | Liver | ||||
| XR575 | Percutaneous insertion of metallic biliary endoprosthesis | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C4620 | Lamellar graft (keratoplasty) to cornea | Xmajor | |||
| C4710 | Repair of corneal wound | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3780 | Repair of cutaneous vesical fistula | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G7403 | Laparoscopic ileostomy | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.12 | Urinary | ||||
| XR661 | Insertion of stent into ureters - bilateral | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q2232 | Open oophorectomy and salpingectomy, +/- biopsy eg. omentum, peritoneum, lymph node (as sole procedure) - unilateral | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7430 | Reconstruction of lateral collateral ligament complex | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H0482 | Laparoscopic restorative proctocolectomy with ileoanal anastomosis and creation of pouch | Extra Major | |||
| 11.9 | Abdominal wall | ||||
| T2415 | Laparoscopic repair of recurrent umbilical/paraumbilical hernia not requiring mesh | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA305 | Augmentation Mammoplasty For Gender Affirmation +/- Implant, +/- Fat Transfer - Bilateral | Major | |||
| GA517 | Hysterectomy +/- Salpingo-Oophorectomy For Gender Affirmation | Extra Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.3 | Duodenum | ||||
| G5000 | Open excision of lesion of duodenum | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA300 | Subcutaneous Mastectomy With Related Chest Reconstruction For Gender Affirmation - Unilateral | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K3500 | Therapeutic transluminal operation(s) on valve of heart | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W3032 | Removal of fixator/frame/pins/wires and change of plaster (as sole procedure) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3720 | Posterior fusion +/- instrumentation - cervical region (1 or 2 levels) Including Spinal Cord Monitoring | Xmajor | |||
| V2950 | Anterior discectomy, decompression and fusion (including bone grafting) - cervical region (1 or 2 levels) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6530 | Endoscopic resection of prostate (TUR) (including cystoscopy) | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| H5240 | Banding of haemorrhoids | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0655 | Removal of benign lesion on head and neck requiring flap closure (excluding advancement flap) (excluding lipoma) | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| C3920 | Cauterisation including cryotherapy to conjunctival lesion | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4080 | Anterolateral access with instrumentation +/- decompression +/- discectomy (including graf stabilisation & all fusion approaches) lumbar region (1 or 2 levels) | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT270 | Insertion and removal of radioactive agent (brachytherapy) into carcinoma of the oesophagus, bronchus or stomach | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F5611 | COMBINED OPEN AND ENDOSCOPIC REMOVAL OF PAROTID GLAND STONE | Intermediate | |||
| 13 | Pregnancy and confinement | ||||
| 13.0 | Pregnancy and confinement | ||||
| R1230 | Transabdominal cerclage for cervial incompetence in gravid uterus | Intermediate | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8551 | Bioadhesive Closure Of Varicose Veins Using Cyanoacrylate - Bilateral | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22025 | Recording and reporting on electromyography and nerve conduction studies (EMG); Myaesthenia Gravis (+ SFEMG) | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0302 | Laparoscopic partial nephrectomy - unilateral | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.5 | Vessels | ||||
| L3400 | Open operations on cerebral artery | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W3651 | Diagnostic aspiration of bone marrow | Minor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4514 | Endoscopic Examination of Bladder (Rigid Cystoscopy) Including any Biopsy | Minor | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X0011 | Consultant supervision of the delivery of a single fraction of orthovoltage radiotherapy | ||||
| X7009 | Delivery of Selective Internal Radiotherapy (SIRT) | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S6041 | Scar revision up to 5cm - trunk & limbs | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4160 | Posterior correction of degenerative adult kyphosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | |||
| V4142 | Removal of posterior scoliosis instrumentation (as sole procedure) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5100 | Endobronchial ultrasound (as sole procedure) | Minor | |||
| 8.9 | Heart – cardiology | ||||
| K6586 | Adult cardiac catheterisation - brachial access (including coronary arteriography/catheterisation of right/left side of heart / contrast radiology) - with pressure wire (including fractional flow reserve measurement) | Intermediate | |||
| K6111 | Insertion of combined biventricular pacemaker and cardioverter defibrillator (CRT-D) | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2283 | Prosthetic intervertebral disc replacement - cervical region (3 or more levels) +/- spinal cord monitoring | Complex | |||
| V3381 | Prosthetic intervertebral disc replacement - lumbar region (3 or more levels) | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR391 | Embolisation of arteriovenous malformation (AVM) e.g. of foot, minor organ | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1818 | Reverse ptosis repair of eyelid | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22029 | Home sleep study including reporting | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| XR161 | Percutaneous image guided fine needle aspiration(s) (FNA) – bilateral | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| J9906 | Heated Intraperitoneal Chemotherapy For Colorectal Peritoneal Carcinomatosis | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4070 | Stabilisation of pars defect + /- instrumentation +/- bone graft +/- spinal monitoring - ** REFER TO SPINE 578 ** | Extra Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2620 | Repair of recurrent incisional hernia requiring mesh | Major | |||
| T2203 | Repair Of Femoral Hernia Requiring Removal Of Previously Inserted Mesh | Major | |||
| T2403 | Repair Of Umbilical/Paraumbilical Hernia Requiring Removal Of Previously Inserted Mesh | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E5590 | Video-Assisted Thoracoscopic Surgery (VATS) Assisted Bullectomy - Unilateral +/- Pleurodesis | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR937 | Insertion of Magnetic Marker for Non-Palpable Breast Lesions under Imaging Control | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 3.8 | Other procedures | ||||
| V5281 | Dynamic CT Myelogram | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7213 | Paediatric Cataract Involving Lensectomy With Lens Implant Bilateral | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| F1140 | Vestibuloplasty | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| T7483 | Ultrasound guided barbotage of calcific deposits of joint (as sole procedure) | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| M5180 | Revision combined abdominal and vaginal operations to support outlet of female bladder (including sling procedures and cystoscopy) | Xmajor | |||
| M5630 | Therapeutic injection into bladder neck for treatment of stress incontinence (periurethral bulking agents), including cystoscopy | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W4900 | Shoulder hemiarthroplasty, as sole procedure | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1120 | Diagnostic ureterorenoscopy (+/- cystoscopy) | Minor | |||
| 12.6 | Genitalia | ||||
| N1320 | Fixation of testis | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9170 | Manipulation of foot/ankle joint under local anaesthetic +/- injection (as a sole procedure) | Minor | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6012 | Planning and preparation for the delivery of magnetic resonance image (MRI) radiotherapy | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR363 | Portal vein embolisation (as sole procedure) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W8645 | Multiple arthroscopic operations on ankle (including soft tissue, bony and/or joint surface procedures with ligament reconstruction). | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| C3780 | Injection of botulinum toxin into extraocular or periocular muscles | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2620 | Frenotomy /frenectomy of tongue under general anaesthetic (as sole procedure) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4840 | Dilatation of tracheal stricture including insertion of stent | Intermediate | |||
| 8.8 | Heart – cardiac surgery | ||||
| K0530 | Double switch procedure (atrial and arterial) | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A3680 | Excision of cerebello-pontine angle tumour | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5700 | Distal pancreatectomy | Xmajor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR306 | Endovascular treatment of cerebral aneurysm | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4510 | Fibreoptic examination of trachea including biopsy/removal of foreign body | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0822 | Amputation of whole ray | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.12 | Urinary | ||||
| XR660 | Insertion of stent into ureters - unilateral | Major | |||
| 18 | Chemotherapy | ||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
|||||
| 18.0 | Chemotherapy | ||||
| X0003 | Clinical supervision and planning for delivery of chemotherapy And/Or Systemic Anti-Cancer Therapy for 1-21 Days | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR964 | Ablation of liver lesion(s) (radiofrequency) | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6016 | Planning for electrons, single field or 2-dimensional radiotherapy on a megavoltage machine, including all imaging and dosimetry | ||||
| X0007 | Clinical supervision of external beam radiotherapy, up to and including 15 fractions or part thereof | ||||
| BT211 | Planning for insertion and removal of high dose rate radioactive agent (brachytherapy) into prostate tumour | ||||
| BT281 | Planning for insertion and removal of radioactive agent (brachytherapy) into the vagina | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR365 | Magnetic Resonance Image-Guided Focused Ultrasound For Ablation of Uterine Fibroids | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N2820 | Reconstruction of penis | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X0009 | Clinical supervision of external beam radiotherapy, for 31 or more fractions | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 16.9 | Hip, leg and pelvis | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7525 | Repositioning of lens implant | Minor | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2917 | Reconstruction of breast using fixed prosthesis and acellular dermal matrix (ADM) (including delayed reconstruction) | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| G2180 | Ambulatory 24h pH and impedance monitoring | ||||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G4690 | Endoscopic submucosal dissection of gastric lesions | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5790 | Ablation of left atrial tachycardia (including mapping) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W0961 | Radical clearance of benign bone tumour with reconstruction +/- insertion of prosthesis | Complex | |||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9045 | Injection(s) +/- aspiration, into two or more joints, cysts, bursae - bilateral | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2593 | Robotic assisted revision repair of hiatus hernia with anti-reflux procedure | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0288 | Laparoscopic partial nephrectomy - bilateral | Major | |||
| 12.3 | Bladder | ||||
| M5223 | Robotic assisted colposuspension | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2208 | Laparoscopic repair of femoral hernia requiring mesh - unilateral | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA400 | Vocal Pitch Increase Surgery For Gender Affirmation Including Glottoplasty +/- Tracheal Shave +/- Cricothyroid Approximation +/- Thyroid Chondroplasty +/- Laser Assisted Voice Adjustment | Major | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| W2912 | Application of halo (as sole procedure) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| XR260 | Angioplasty with insertion of metallic stent | Major | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| X4110 | Open insertion of Tenckhoff catheter | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1720 | Revision stapedectomy (as sole procedure) | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N2842 | Frenuloplasty of penis | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W3100 | Bone graft (as sole procedure) | Major | |||
| 16.6 | Hand | ||||
| T5410 | Dupuytren’s subcutaneous fasciotomy Minor | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2162 | Therapeutic arthroscopic operation of temporomandibular joint +/- lysis and/or lavage - bilateral | intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| C5480 | Removal of silicone oil | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1110 | Diagnostic endoscopic examination of kidney (including biopsy) | Major | |||
| 12.5 | Prostate | ||||
| M6580 | Endoscopic biopsy of prostate (including cystoscopy) | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q1131 | Hysteroscopic Removal Of Retained Products Of Conception | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| V6070 | Thoracic outlet decompression surgery (as sole procedure) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1073 | Hemi-maxillectomy for benign tumour | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2995 | Reconstruction of breast using stacked flap (including delayed reconstruction) not elsewhere classified - bilateral (2 flaps per breast) | complex | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3500 | Fixation of rectum for prolapse | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T3600 | Wedge excision or removal of omentum (as sole procedure) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F5020 | Transposition of submandibular duct (including bilateral) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR442 | Embolisation of varicocele of gonadal vein | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| L0610 | Formation of atriopulmonary connection (or any modification of Fontan type procedure) | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR370 | Embolisation of bronchial artery | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1680 | Parathyroid: re-operation | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0330 | Pinnaplasty (including bilateral) (child 14 and below only) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3780 | Total prosthetic replacement of the hip, with or without cement, bilateral | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA507 | Phalloplasty Stage 3 With No Implantations For Gender Affirmation | Complex | |||
| GA509 | Repair Of Resultant Defect Following Phalloplasty For Gender Affirmation | Complex | |||
| GA521 | Placement Of Penile And Testicular Prostheses For Gender Affirmation | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA201 | Excision Of Lesion Of Mullerian Duct Remnant For Gender Affirmation | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W6630 | Primary closed reduction of fracture or dislocation of joint, with or without fixation including cast application | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| F3490 | INTRACAPSULAR TONSILLECTOMY | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9035 | Injection(s) +/- aspiration, into two or more joints, cysts, bursae with image guidance - bilateral | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0521 | Microscopically controlled excision of lesion of skin or subcutaneous tissue (Mohs micrographic surgery) without reconstruction | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3412 | Laparoscopic cystoprostatectomy (with construction of intestinal conduit or bladder) | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT222 | Insertion and removal of high dose rate radioactive agent (brachytherapy) into prostate tumour | ||||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B3043 | Mastectomy and immediate reconstruction of breast using fixed prosthesis - bilateral | Extra Major | |||
| 7.4 | Other | ||||
| B3130 | Unilateral Mastopexy | Extra Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| B2234 | Robotic assisted adrenalectomy - unilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3742 | 2 Stage Revision Of Total Hip Replacement For Infection - First Stage | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D2822 | Examination of ear under general anaesthetic (as sole procedure) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3380 | Prosthetic intervertebral disc replacement - lumbar region (1 or 2 levels) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| A2780 | Vagotomy and pyloroplasty | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| W2620 | Manipulation under anaesthesia of fractured nose (as sole procedure) | Minor | |||
| 5.7 | Larynx and trachea | ||||
| E3100 | Reconstruction of larynx with graft | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| F2810 | Excision/destruction of lesion of palate | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.10 | Vitreous | ||||
| C7910 | Anterior vitrectomy | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| A1060 | Fiducial Placement | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S6040 | Scar Revision up to 5cm - Head & Neck | Minor | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| B3120 | Augmentation Mammoplasty - Unilateral | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2601 | Sutureless aortic valve replacement for aortic stenosis | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5765 | Neurolytic Root Block (Radiofrequency denervation, Thermocoagulation, Cryotherapy or Phenol, including Rhizolysis) +/- Image Guidance (including Bilateral) LUMBAR | MAJOR | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| X3060 | Sub-tenons anaesthesia administered by anaesthetist (as sole procedure) | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2541 | Posterior excision of disc prolapse (including microdiscectomy +/- decompression) - lumbar region (3 or more levels) | Xmajor | |||
| 3.3 | Paraspinal injections | ||||
| V2510 | Endoscopic discectomy and/or decompression (transforaminal) - lumbar region | Extra Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2120 | Total removal of vaginal mesh/tape with reconstruction of vagina and/or uretha, including cysoscopy and/or proctoscopy [fees on application] | Complex | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7511 | Excision of arteriovenous malformation from peripheral vessel | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0324 | Revision Of Osteotomy/Ies (Eg Scarf And Akin) For Hallux Valgus Correction +/- Internal Fixation +/- Soft Tissue Correction - Bilateral | Extra Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T9020 | Sentinel node mapping and sampling with blue dye and radioactive probe for breast cancer | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0515 | Interpositional silastic arthroplasty of metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joints - multiple digits | major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2988 | Reconstruction of breast using ALT (anteriolateral thigh) flap including delayed reconstruction | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0814 | Open biopsy of native kidney | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S2500 | Local flap ? less than 9cm2 | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W2700 | Fixation of epiphysis, including epiphysiodesis, correction of angular deformity | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J6600 | Therapeutic percutaneous operations on pancreas | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W7483 | Triquetrolunate ligament reconstruction | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2930 | Removal of prosthesis from ureter (including cystoscopy) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4180 | Distraction Of Spinal Magnetic Growth Rods For Idiopathic Juvenile Scoliosis | Minor | |||
| 3.3 | Paraspinal injections | ||||
| A5755 | Nerve root block +/- image guidance (including bilateral) lumbar | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.7 | Teeth | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5744 | Medial Branch Block Injection(s) +/- Image Guidance (Including Bilateral) Thoracic | Intermediate | |||
| A5743 | Medial branch block injection(s) +/- image guidance (including bilateral) CERVICAL | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5580 | Endoscopic Ablation for an Anal Fistula without Flap | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T0214 | Minimally invasive pectus bar placement for pectus excavatum (including bilateral) | extra major | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9980 | Sclerotherapy of Lymphatic or Peripheral venous malformation | Intermediate | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X7019 | Delivery Of A Fraction Mr Linac Adaptive Planned Radiotherapy, Including Image Guidance | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P1800 | OTHER OBLITERATION OF VAGINA | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT216 | Oral introduction of liquid radioactive agent for benign thyroid disease | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2433 | Sacrocolpopexy (Including Laparoscopic) +/- Ureterolysis, Using Tissue Graft | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0330 | Exploratory burr hole of cranium | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| X0720 | Disarticulation of shoulder | XMajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G2800 | Partial gastrectomy | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.3 | Trachea | ||||
| E4230 | Mini-tracheostomy (percutaneous) | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W1649 | Complex pelvic osteotomies and fixation, eg triple osteotomy, peri-acetabular osteotomy | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V0980 | Open reduction of fracture of zygomatic complex of bones | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2080 | Primary repair of strangulated inguinal hernia | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| F0420 | Reconstruction of lip using skin flap | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5790 | Sacroiliac joint injection under image guidance (and bilateral) | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q2081 | Myolysis of uterine fibroids | Major | |||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L4530 | Endarterectomy and patch repair of visceral branch of abdominal aorta | Complex | |||
| 9.6 | Non-specific | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7340 | YAG (Yttrium Aluminium Garnett) Laser Photodisruption Of Posterior Capsule Of Lens (Including Laser Capsulotomy) - Unilateral | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1380 | Endoscopic balloon dilation sphenoid sinuplasty and bilateral | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| F0200 | Excision of lesion of lip | Intermediate | |||
| 6.8 | Neck | ||||
| T9420 | Operations on branchial fistula | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1522 | Correction of entropion - lower lid | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2431 | Robotic Assisted Sacrocolpopexy +/- Ureterolysis, Using Tissue Graft | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2408 | Laparoscopic repair of umbilical/paraumbilical hernia requiring mesh | Intermediate | |||
| T2513 | Laparoscopic repair of parastomal hernia not requiring mesh | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| J3800 | Therapeutic ERCP without insertion of stents | Intermediate | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7260 | Intravascular ultrasound of non-coronary arteries and veins (as sole procedure, not otherwise specified) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2571 | Percutaneous Vertebroplasty - 3 or more levels | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6999 | Planning and delivery of a single course of radiotherapy for keloid scar | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2592 | Laparoscopic Revision Repair Of Hiatus Hernia With Anti-Reflux Procedure | complex | |||
| 11.1 | Oesophagus | ||||
| G2594 | Robotic assisted revision of anti-reflux operation | Complex | |||
| 11.6 | Rectum/anus | ||||
| H5560 | Ligation of the intersphincteric fistula tract (LIFT) for the treatment of anal fistula without mesh/plug or video assistance | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA519 | Clitoroplasty (Creation Of Clitoris) For Gender Affirmation | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7487 | Allograft Posterior Cruciate Ligament Reconstruction +/- Meniscectomy | Extra Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0301 | Robotic assisted sub-total oesophagectomy with anastomosis in neck | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G2711 | Robotic assisted total gastrectomy and excision of surrounding tissue | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3411 | Robotic assisted cystoprostatectomy (with construction of intestinal conduit or bladder) | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6009 | Planning and preparation for the delivery of Selective Internal Radiotherapy (SIRT) | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6772 | Total gland High Intensity Focused Ultrasound of Prostate (including Cystoscopy) | Complex | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| J3700 | Endocrine Surgery, Hepato-Biliary Surgery | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| T6782 | Repair of distal biceps tendon | Major | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G8084 | Diagnostic Oesophago-Gastro-Duodenos (OGD) & Immediate Flexible Sigmoidoscopy | Intermediate | |||
| 18 | Chemotherapy | ||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
|||||
| 18.0 | Chemotherapy | ||||
| x0005 | Clinical supervision and planning for delivery of chemotherapy And/Or Systemic Anti-Cancer Therapy For 1-56 Days | Non | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6575 | Planning, preparation and the delivery of peptide receptor radionuclide therapy for neuroendocrine tumours. | ||||
| X6020 | Planning and preparation of the delivery of Total body surface skin radiotherapy (TSEBT) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2761 | Laparoscopic Repair of Spigelian Hernia with Mesh | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K0970 | Percutaneous covered stent correction of sinus venosus atrial septal defect | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5211 | Epidural injection (caudal) | Minor | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.1 | Bone Marrow | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2152 | Arthrocentesis of temporomandibular joint - bilateral | Minor | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3382 | Proctectomy | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C4630 | Perforating graft (keratoplasty) to cornea | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0920 | Oesophagocardiomyotomy (Heller's operation) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| T1100 | Diagnostic thoracoscopy (+/- biopsy) | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.3 | Meninges | ||||
| A4010 | Evacuation of extradural haematoma | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA505 | Phalloplasty Stage 3 With Penile Implant For Gender Affirmation | Complex | |||
| GA506 | Phalloplasty Stage 3 With Testicular And Penile Implant For Gender Affirmation | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0922 | Laser destruction of lesion(s) of skin - up to 25cm² in area | Minor | |||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L1980 | Elective repair of aneurysm of arch of aorta | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6002 | Planning and preparation for the delivery of Stereotactic Body radiotherapy (SBT)/Stereotactic Ablative Body radiotherapy (SABR) | ||||
| X0010 | Clinical supervision of intraoperative radiation therapy (IORT) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W8646 | Multiple Arthroscopic Operations On Ankle (Including Soft Tissue +/- Bony +/- Joint Surface Procedures) Without Ligament Reconstruction | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S6043 | Scar revision over 5cm - trunk & limbs | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1540 | Surgical correction of trichiasis/upper lid entropion, including graft/flap | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| T5540 | Fasciotomy of limb | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E4100 | Insertion of voice prosthesis (TOF) | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.6 | Other | ||||
| B0100 | Open hypophysectomy (including total) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0812 | Removal of solitary osteoma of EAC | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0606 | Photodynamic therapy (PDT) To Malignant Lesion Of Skin, With Artificial Light Source, Up To Three | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0514 | Reconstruction of socket with implant and graft | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6583 | Transperinal MRI - US Fusion Targeted Prostate Biopsy | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5763 | Neurolytic Root Block (Radiofrequency denervation, Thermocoagulation, Cryotherapy or Phenol, including Rhizolysis) +/- Image Guidance (including Bilateral) CERVICAL | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1931 | Alveolar bone graft - bilateral | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| X3531 | Sedation or general anaesthesia for MRI scan | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6011 | Canaloplasty (of Schlemm?s Canal with microcatheter) (including topical or local anaesthetic) | major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A7310 | Biopsy of peripheral nerve | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0520 | Ligation of artery of internal nose (including endoscopic, as sole procedure) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5100 | Aorto-iliac, aorto-femoral, ilio-femoral bypass | Complex | |||
| 9.8 | Lymphatic system | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H2502 | Diagnostic flexible sigmoidoscopy, including forceps biopsy and proctoscopy | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9032 | Injection of viscosupplement into joint with image guidance - unilateral | Minor | |||
| 16.11 | Foot | ||||
| W6015 | Open ankle arthrodesis with internal fixation | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H1883 | Laparoscopic left hemicolectomy +/- stoma | Extra Major | |||
| H3366 | Laparoscopic Hartmanns procedure | Extra Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N1380 | Bilateral fixation of testis | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S2002 | Small island flap (less than 9cm2) | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3740 | Second, third or further revision total hip replacement (excluding acetabular liner and head changes) | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K4900 | Percutaneous transluminal angioplasty of coronary artery(ies) (including laser) | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| W0950 | Radical clearance of sarcoma of trunk or limbs, +/- amputation or insertion of prosthesis | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4081 | Anterolateral access with instrumentation +/- decompression +/- duscectomy (including graf stabilisation and all fusion approaches) -lumbar region (3 or more levels) | Complex | |||
| 3.2 | Spinal cord | ||||
| A4860 | Implantation/removal of epidural delivery system | Major | |||
| 3.8 | Other procedures | ||||
| V5484 | Interspinous dynamic stabilisation procedure | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0280 | Awake craniotomy with ablation of lesion of brain with or without cortical mapping/stereotaxy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0730 | Repair of congenital oesophageal atresia (with or without fistula) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L0310 | Percutaneous transluminal prosthetic occlusion of patent ductus arteriosus | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W5701 | Excision arthroplasty of first metatarsophalangeal joint with prosthetic implantation or interposition arthroplasty - bilateral | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2030 | Bilateral replantation of ureter into bladder | Xmajor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.7 | Head and neck | ||||
| XR320 | Dilatation/stenting of nasolacrimal duct under imaging control | Major | |||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L2600 | Percutaneous transluminal balloon operations on aorta | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0412 | De-roofing and aspiration of renal para pelvic cyst | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T0133 | Excision of chest wall tumour - without chest wall reconstruction | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A2900 | Excision of lesion of cranial nerve (intracranial) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W5790 | Repair to plantar plate | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2918 | Mastectomy and immediate reconstruction of breast using fixed prosthesis and acellular dermal matrix (ADM) - unilateral | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4740 | Image guided percutaneous spinal biopsy | Major | |||
| 3.2 | Spinal cord | ||||
| A4831 | Trial of neurostimulator to spinal cord (as sole procedure) not at time of permanent implant | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S4213 | Debridement and primary suture of wound without involvement of deeper tissue (skin and subcutaneous fat only) - Trunk and Limbs | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0412 | Reduction turbinates of nose (laser, diathermy, out fracture etc) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.3 | Duodenum | ||||
| G5320 | Closure of perforated ulcer of duodenum | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0310 | Drainage of abscess of appendix or drainage of intra-abdominal abscess | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X1110 | Amputation of toe | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E4400 | Carinal resection +/- pneumonectomy | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.6 | Other | ||||
| B0410 | Transsphenoidal hypophysectomy (including total) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G7513 | Revision of ileostomy - laparotomy | Major | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2161 | Therapeutic arthroscopic operation of temporomandibular joint +/- lysis and/or lavage -unilateral | intermediate | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8562 | LAPAROSCOPIC PELVIC LYMPHADENECTOMY (AS SOLE PROCEDURE) | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| S5211 | Injection of Botulinum Toxin for Hyperhidrosis | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6011 | Planning and preparation for the delivery of superficial radiotherapy with imaging, dosimetry and calculation using orthovoltage | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A2080 | Ventricular puncture (as sole procedure) | Minor | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B2760 | Skin/Nipple sparing mastectomy (including axillary node biopsy) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0340 | Closure of perforation of septum of nose | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.5 | Vulva/labia | ||||
| P0320 | Marsupialisation of Bartholin cyst | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3322 | Laparoscopic abdominoperineal resection +/- stoma | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1890 | Insertion of weight to upper eyelid | Intermediate | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8530 | Operations for recurrent varicose veins with re-exploration of groin and/or popliteal fossa - unilateral | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1882 | Cholecystectomy with peri-operative cholangiogram | Extra Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA523 | Scrotoplasty (Creation Of Scrotum) For Gender Affirmation | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W4240 | 2 stage revision of total knee replacement for infection – first stage | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4150 | Anterior correction of degenerative adult kyphosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S4950 | Fat transfer, including extraction and volume adjustment, of scar defect following trauma (excluding breast) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E4032 | Tracheoplasty for congenital conditions | Complex | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0422 | Triple fusion of joints of hindfoot with autogenous graft | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3210 | Gastro–jejunostomy | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7315 | Secondary adjustment of penile skin following hypospadias repair | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.1 | Investigations | ||||
| 64301 | Echocardiography including bubble contrast (including reporting) as sole procedure | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N3020 | Division of preputial adhesions | Minor | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1640 | Tarsorrhaphy | Intermediate | |||
| 4.3 | Lacrimal system | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2984 | Reconstruction of breast using pedicled TRAM (including delayed reconstruction) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| T1410 | Needle biopsy of pleura | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6180 | Radical prostatectomy, reconstruction of bladder neck including bilateral pelvic lymphadenectomy (including cystoscopy) | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1812 | Correction of ptosis of eyelid - complex | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| X2200 | Closed reduction and Frog POP for congenital dislocation of hip (including dynamic arthrogram, traction and soft tissue release) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6533 | Holmium Laser Enucleation of Prostatic Adenoma (HoLEP) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N2780 | Operation for Peyronie's disease (eg Nesbitt's) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K5121 | Intravascular ultrasound with peripheral angioplasty +/- stent | intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H0484 | Laparoscopic panproctocolectomy +/- stoma | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3140 | VATS percutaneous discectomy +/- fusion (thoracic region) including spinal cord monitoring | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6080 | Neurectomy (major nerve) | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2210 | Anterior +/- posterior colporrhaphy and amputation of cervix uteri (including primary repair of enterocele) | Major | |||
| 9 | Vascular system | ||||
| 9.1 | Head and neck | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2764 | Open repair of Spigelian hernia without mesh | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.1 | Investigations | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W7719 | Primary open shoulder stabilisation procedure (including labral/SLAP/tendon repair | Major | |||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L2760 | Endovascular insertion of stent graft for aorto- Monoiliac EVAR monoiliac aneurysm with ileo/femfem crossover bypass graft | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5210 | Epidural injection (lumbar) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0312 | Microwave ablation for primary or metastatic cancer of the liver | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2432 | Sacrocolpopexy (Including Laparoscopic) +/- Ureterolysis, Using Mesh | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2580 | Repair of mitral valve | Complex | |||
| 13 | Pregnancy and confinement | ||||
| 13.0 | Pregnancy and confinement | ||||
| X0920 | Disarticulation of hip | Extra Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5521 | Robotic assisted excision of lesion of lung | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0301 | Robotic assisted sub-total oesophagectomy with anastomosis in neck | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E4401 | Robotic assisted carinal resection +/- pneumonectomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0516 | Interpositional silastic arthroplasty of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints - single digit | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0103 | Robotic assisted Oesophagectomy/Oesophagogastrectomy with anastomosis in chest | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3722 | Minimally Invasive Hip Replacement +/- Cement - Bilateral | Extra Major | |||
| 16.11 | Foot | ||||
| W4430 | Revision of total prosthetic replacement of ankle joint | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.7 | Teeth | ||||
| F0830 | Replantation of natural tooth/teeth following trauma | Intermediate | |||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1012 | Excision of thyroglossal cyst/tract | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1410 | External frontoethmoidectomy and bilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W6540 | Open reduction of dislocated hip prosthesis | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A3300 | Implantation of neurostimulator to cranial nerve | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1820 | Cholecystectomy with exploration of common bile duct | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| C3112 | Surgical correction of squint - unilateral | Major | |||
| 4.11 | Retina | ||||
| C8200 | Laser photocoagulation/cryotherapy of lesion of retina | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| F4308 | Transoral robotic assisted mucosectomy for microscopic primary tumour (as sole procedure) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L2730 | Endovascular insertion of stent graft for thoracic TEVAR | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| W7460 | Proximal Hamstring Repair | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0110 | Total excision of pinna | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N3010 | Preputioplasty | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W7486 | Carpo-metacarpal joint ligament reconstruction | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1230 | Core biopsy of thyroid gland | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G7402 | Open formation of ileostomy | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T8003 | Major release of muscle for pain or contracture (eg Quadriceps) (involving large joint) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0100 | Oesophagectomy/oesophagogastrectomy with anastomosis in chest | Complex | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L6530 | Revision femoral bypass graft | Xmajor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8750 | Local excision (multiple phlebectomy) of varicose vein(s) of leg - unilateral | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| Q2020 | Endometrial biopsy or aspiration | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6710 | Primary repair of extensor of hand | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| V5486 | Pedicle based dynamic soft stabilisation procedure (e.g graf ligament) | Extra Major | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H2002 | Diagnostic colonoscopy, includes forceps biopsy of colon and ileum | Intermediate | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6004 | Forward planning and preparation for the delivery of intensity modulated radiotherapy (IMRT), including adaptive IMRT | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2981 | LOCAL MOBILISATION OF GLANDULAR BREAST TISSUE TO FILL SURGICAL CAVITY | INT | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1210 | Excision of lesion of eyelid | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2680 | Endoscopic removal and insertion of prosthesis into ureter (including cystoscopy) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8540 | Open block dissection of para-aortic lymph nodes | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M7080 | Insertion of urethral stent for relief of prostatic obstruction (including cystoscopy) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3440 | Closure of Gastrostomy | Major | |||
| 11.4 | Small intestine | ||||
| G7250 | Ileoanal anastomosis and creation of pouch | Complex | |||
| 11.7 | Other organs (mainly digestive) | ||||
| J0222 | Laparoscopic hemi-hepatectomy (resection of four or more segments) +/- cholecystectomy | Complex | |||
| J0231 | Laparoscopic hemi-hepatectomy (hepatectomy or resection of up to three segments) +/- cholecystectomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F5010 | Transposition of parotid duct (including bilateral) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1900 | Middle ear tumour excision | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1330 | Intranasal antrostomy including endoscopic and antral washout (including bilateral) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2762 | Open repair of Spigelian hernia with mesh | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2150 | Reconstruction free jejunal graft following pharyngolaryngectomy | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5580 | ENDOSCOPIC ABLATION FOR AN ANAL FISTULA WITHOUT FLAP | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| F4306 | Transoral robotic assisted horizontal supra-glottic laryngectomy (as sole procedure) | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3590 | Stapled transanal rectal resection (STARR) for obstructed defaecation syndrome | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4230 | Endoscopic destruction of lesion of bladder (including cystoscopy) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR940 | Retrieval of foreign body under X-ray guidance | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K5330 | Repair of post infarction ventricular septal defect | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| A7081 | Percutaneous posterior tibial nerve stimulation (PTNS) for overactive bladder (OAB) syndrome or faecal incontinence | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6580 | Carpal tunnel release (open) - bilateral | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E4600 | Sleeve resection of bronchus or pulmonary artery with pulmonary resection | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W5600 | Primary repair of rupture of acromioclavicular or sternoclavicular joint +/- internal fixation | Xmajor | |||
| 16.10 | Knee | ||||
| W5201 | Unicompartmental knee replacement - bilateral | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| J9901 | Cytoreductive surgery (Sugarbaker technique) for Pseudomyxoma Peritonei with intraperitoneal chemotherapy | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4210 | Endoscopic resection of lesion of bladder (including cystoscopy) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0310 | Reconstruction of external ear for anotia/microtia using cartilage | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3392 | Laparoscopic reversal of Hartmann's procedure | Complex | |||
| 11.7 | Other organs (mainly digestive) | ||||
| J0313 | Laparoscopic assisted excision of liver tumour | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA301 | Subcutaneous Mastectomy With Related Chest Reconstruction For Gender Affirmation - Bilateral | Major | |||
| GA304 | Augmentation Mammoplasty For Gender Affirmation +/- Implant, +/- Fat Transfer - Unilateral | Major | |||
| GA502 | Phalloplasty Stage 1 (Using Anterolateral Thigh Tissue) For Gender Affirmation | Complex | |||
| GA516 | Orchidectomy (Removal Of Testes) For Gender Affirmation - Unilateral | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T5210 | Dupuytren’s fasciectomy multiple digits with proximal interphalangeal joints | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5480 | Lung resection with resection of chest wall | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.2 | Drainage | ||||
| XR190 | CT/MRI guided drainage of fluid collection | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5410 | Pneumonectomy | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2920 | Horizontal supra-glottic laryngectomy | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2700 | Replacement of tricuspid valve (including valvuloplasty) | Complex | |||
| 8.9 | Heart – cardiology | ||||
| K2280 | Percutaneous occlusion of left atrial appendage | Xmajor | |||
| 8.9 | Heart – cardiology | ||||
| K6000 | Cardiac pacemaker system introduced through vein (single chamber) | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2932 | Examination of vagina under anaesthetic as sole procedure | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W3122 | Harvesting for autologous chondrocyte transplantation into knee including arthroscopy | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A1700 | Therapeutic endoscopic operations on ventricle of brain (including examination and biopsy of lesion) | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.3 | Trachea | ||||
| E4210 | Tracheostomy | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3390 | Reversal of Hartmann's procedure | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W0960 | Excision of benign tumour of bone with bone grafting | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M3111 | Holmium Laser Lithotripsy for calculi of ureter (including cystoscopy and insertion/removal of stent) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5830 | Endomyocardial biopsy | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E6710 | Bronchial thermoplasty (including bronchoscopy) for severe asthma | Minor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G1422 | Endoscopic Circumferential Ablation Of Dysplasia In Barrett's Oesophagus | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2000 | Excision of lesion of vagina (e.g. warts and cysts) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5753 | Nerve root block +/- image guidance (including bilateral) cervical | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1110 | Excision of lesion of canthus | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A7340 | Exploration and grafting of brachial plexus | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.5 | Thrombolysis | ||||
| XR410 | Thrombolysis or aspiration of thrombus under imaging control | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| F0313 | Primary closure of cleft lip - bilateral | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M5580 | Excision of urethral caruncle | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0910 | Hindquarter amputation | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 16.10 | Knee | ||||
| W4244 | Tibial liner exchange in total knee replacement | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| AA461 | Balloon compression of trigeminal ganglion | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA302 | Chest Reconstruction For Gender Affirmation (As Sole Procedure) - Unilateral | Major | |||
| GA303 | Chest Reconstruction For Gender Affirmation (As Sole Procedure) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3388 | Laparoscopic proctectomy +/- stoma | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA511 | Peritoneal, Intestinal Or Sigmoid Vaginoplasty For Gender Affirmation | Complex | |||
| GA512 | Penile Inversion Vaginoplasty For Gender Affirmation | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L9510 | Venography (and bilateral) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H0410 | Panproctocolectomy and ileostomy | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.11 | Other | ||||
| A2730 | Highly selective vagotomy | Major | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5923 | Femoro-popliteal bypass using vein | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR917 | Peripherally inserted central venous catheters (PICCs) under X-ray guidance | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2600 | Therapeutic nephroscopic operations on ureter (including cystoscopy) | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q1802 | Hysteroscopy with resection of fibroids (excluding morcellation) +/- insertion on Mirena coil | Major | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H2001 | Double balloon enteroscopy | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6080 | Removal of pacing system without bypass (including leads) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2570 | Percutaneous vertebroplasty - 1 level | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T8002 | Minor release of muscle for pain or contracture (involving small joint) | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H2380 | ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) OF COLORECTAL POLYP | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T3920 | Multivisceral resection of retroperitoneal sarcoma | Extra Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0940 | Amputation of leg through knee | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| A5440 | CT-guided epidural blood patch (single level) | Minor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0340 | Soft tissue meatoplasty of EAC | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2310 | Excision/destruction of lesion of tongue | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1830 | Laparoscopic cholecystectomy | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| G2331 | Laparoscopic repair of hiatus hernia with anti-reflux procedure (eg fundoplication) | Major | |||
| 8.8 | Heart – cardiac surgery | ||||
| K2610 | Ross procedure | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W6522 | Primary open reduction of dislocation of small joint | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S1420 | Shave biopsy of lesion of skin | Minor | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6880 | Insertion of Prostatic Urethral Lift Implants (Including Cystoscopy) | Intermediate | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X0008 | Clinical supervision of external beam radiotherapy, for 16 or up to and including 30 fractions | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3580 | Nipple areola complex reconstruction +/- liposuction and fat transfer | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.3 | Meninges | ||||
| A2210 | Drainage of subarachnoid space of brain | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H6020 | Laying open of pilonidal sinus | Minor | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8541 | Radiofrequency ablation of more than one venous trunk +/- phlebectomies - bilateral | Major | |||
| 9.8 | Lymphatic system | ||||
| T8723 | Selective dissection of cervical lymph nodes, levels 1 to 5 (+/- 6) | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1240 | Vidian neurectomy (including endoscopic) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25030 | Stellate ganglion block (neurolytic) +/- Image Guidance | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W8840 | Diagnostic arthroscopic examination of ankle including anterior synovectomy to gain vision (as sole procedure) | Intermediate | |||
| 16.12 | External fixation/traction | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K0500 | Atrial inversion for transposition of great vessels | Complex | |||
| 8.10 | Great Vessels | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.8 | Neck | ||||
| T8722 | Selective dissection of cervical lymph nodes, levels 1 to 4 | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| A2953 | Excision of acoustic neuroma (vestibular schwannoma) - tumours more than 2.5cm or compressing brain stem (performed by single surgeon) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T5222 | Dupuytren’s dermofasciectomy and graft, or for recurrent disease – single digit | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K6810 | Decompression of cardiac tamponade or re-exploration for bleeding | Xmajor | |||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L1810 | Repair of leaking aneurysm of ascending aorta | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6300 | Graft to peripheral nerve | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| F2910 | Primary repair of cleft palate | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M3010 | Endoscopic retrograde pyelography (including bilateral and cystoscopy) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| G7250 | Ileoanal anastomosis and creation of pouch | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E5180 | Diagnostic bronchoscopy +/- biopsy | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E3400 | Cordectomy (endoscopic) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L2302 | Coarctation repair | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0342 | Boney meatoplasty | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| V4980 | Excision of intramedullary tumour | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.4 | Palate | ||||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0610 | Biopsy of lesion of pinna (as sole procedure) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5766 | Neurolytic Root Block (Radiofrequency denervation, Thermocoagulation, Cryotherapy or Phenol, including Rhizolysis) +/- Image Guidance (including Bilateral) CAUDAL | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5703 | Thoracotomy bullectomy - bilateral +/- pleurodesis | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2994 | Reconstruction of breast using stacked flap (including delayed reconstruction) not elsewhere classified - unilateral (2 flaps) | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1532 | Correction of trichiasis by electrolysis/diathermy/cryotherapy/laser | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3719 | Hip Resurfacing Arthroplasty - Bilateral | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2503 | Laparoscopic repair of incisional hernia not requiring mesh | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8881 | Endovenous mechanochemical ablation for varicose veins - bilateral | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| X3530 | Sedation or general anaesthesia for CT scan | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1020 | Modified radical mastoidectomy (including meatoplasty) | Xmajor | |||
| D1421 | Fat Plug Myringoplasty | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7214 | Paediatric cataract involving lens aspiration and implant unilateral | Intermediate | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3700 | Removal of port or valve from permanent expandable breast prosthesis +/- image guidance | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2530 | Ureterolysis ? unilateral | Major | |||
| 12.3 | Bladder | ||||
| M4780 | Invasive urodynamic assessment including cystoscopy and pressure/flow measurements | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.7 | Sclera | ||||
| C5300 | Excision of lesion of sclera | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8680 | Therapeutic arthroscopy operation on cavity of joint - bilateral (not otherwise specified) (as sole procedure) | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| BT342 | Insertion and removal of a radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2312 | Transthoracic repair of paraoesophageal hiatus hernia | Xmajor | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| B3212 | Percutaneous suction core biopsy | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| X4822 | Change of cast under general anaesthetic (as sole procedure) | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1710 | Stapedectomy (as sole procedure) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0980 | Thorascopic oesophagogastric myotomy | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6760 | Photoselective vaporisation of prostate (GreenLight/Niagara laser PVP) (including cystoscopy) | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.3 | Duodenum | ||||
| 11.6 | Rectum/anus | ||||
| H4000 | Transanal resection for local rectal growth | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5940 | Excision of pilonidal sinus and suture/skin graft | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8751 | Local excision (multiple phlebectomy) of varicose vein(s) of leg - bilateral | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0603 | Primary excision of malignant lesion - trunk and limbs | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4510 | Fibreoptic examination of trachea +/- biopsy/removal of foreign body | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| Y3811 | Removal of Indwelling pleural catheter performed by consultant | Minor | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6017 | Planning and preparation for the delivery of Proton Beam Therapy (PBT) for non-ocular paediatric tumours | ||||
| X6014 | Planning and preparation for the delivery of low dose brachytherapy (not otherwise specified) | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6010 | Surgical trabeculectomy or other penetrating glaucoma procedures (including topical or local anaesthetic) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.7 | Other nerve blocks | ||||
| A7301 | Radiofrequency denervation of knee (under image guidance) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M2890 | Push manipulation of stone prior to lithotripsy (as sole procedure) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W4242 | 2 stage revision of total knee replacement for infection – second stage | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| C2540 | Dacryocystorhinostomy (including insertion and later removal of tube) | Major | |||
| 4.8 | Iris and anterior chamber | ||||
| C6930 | Injection into anterior chamber (including topical or local anaesthetic) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5764 | Neurolytic Root Block (Radiofrequency denervation, Thermocoagulation, Cryotherapy or Phenol, including Rhizolysis) +/- Image Guidance (including Bilateral) THORACIC | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0530 | Elevation of depressed fracture of cranium | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W3530 | Removal of percutaneous wire | Minor | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR362 | Embolisation of pelvic vein varices | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3300 | Percutaneous intradiscal laser ablation (lumbar region) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| D2620 | Membranous labyrinthectomy | Xmajor | |||
| 5.7 | Larynx and trachea | ||||
| E4210 | Tracheostomy | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3380 | Partial excision of rectum and sigmoid colon for prolapse | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.3 | Meninges | ||||
| A4180 | Subdural haemorrhage – tap | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5533 | Percutaneous radiofrequency ablation of malignant neoplasm of lung | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N1580 | Excision of epididymal cyst | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K4912 | Percutaneous transluminal angioplasty of coronary artery(ies) with stent insertion and intravascular ultrasound | Complex | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8594 | Laparoscopic para-aortic lymph node dissection | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.5 | Vessels | ||||
| L3380 | Reinforcement of aneurysm of cerebral artery | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.8 | Spine | ||||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| T9000 | Sentinel node mapping and sampling with blue dye or radioactive probe for breast cancer | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3944 | Acetabular liner and head changes | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2400 | Repair of umbilical/paraumbilical hernia (irrespective of age) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA520 | Labiaplasty (Creation Of Labia) For Gender Affirmation | Complex | |||
| GA522 | Urethroplasty (Creation Of Urethra) For Gender Affirmation | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3810 | Reconstruction of breast using SGAP (superior gluteal artery perforator) flap including delayed reconstruction. | Complex | |||
| 7.4 | Other | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V1423 | Extensive excision of mandible with disarticulation | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2740 | Repair of perineal hernia including scrotal that are not inguinal | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W5940 | Fusion of interphalangeal joint(s) of toe (including internal fixation - unilateral | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6006 | Planning and preparation for the delivery of static total body irradiation (TBI) | ||||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B3042 | Mastectomy and immediate reconstruction of breast using expandable prosthesis - bilateral | Extra Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2640 | Repair of recurrent incisional hernia requiring removal of previously inserted mesh | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3743 | 2 Stage Revision Of Total Hip Replacement For Infection - Second Stage | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| Q5451 | Robotic assisted laparoscopic hysteropexy (including sacrohysteropexy) using mesh +/- ureterolysis | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0102 | Robotic assisted radical Oesophagectomy / Oesophagogastrectomy including dissection of mediastinal lymph nodes | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2226 | Laparoscopic repair of recurrent femoral hernia requiring mesh - bilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7630 | Reconstruction Of Medial Collateral Ligament Complex | Major | |||
| W7481 | Autograft posterior cruciate ligament reconstruction +/- meniscectomy | Extra Major | |||
| 16.11 | Foot | ||||
| W7922 | SURGICAL CORRECTION OF HALLUX VALGUS USING MINIMAL ACCESS TECHNIQUES - UNILATERAL | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6013 | Planning and preparation for the delivery of Proton Beam Therapy (PBT) for ocular tumours | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2622 | FRENOTMY/FRENECTOMY OF TONGUE WITHOUT LOCAL ANAESTHETIC OR GA | Minor | |||
| 9 | Vascular system | ||||
| 9.3 | Renal vessels | ||||
| L4300 | Transluminal operations on renal artery | Major | |||
| 9.8 | Lymphatic system | ||||
| T8542 | Laparoscopic block dissection of para-aortic lymph nodes | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0950 | Amputation of leg below knee | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5761 | Pulsed Field Ablation (PFA) of paroxysmal atrial fibrillation (including mapping) | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S5562 | Release of burn scar contracture, trunk and limbs | Major | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B2710 | Radical mastectomy including block dissection | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4430 | Endoscopic removal of foreign body from bladder (including cystoscopy) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| 25160 | Trigeminal ganglion radiofrequency lesion (under X-ray control) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.3 | Renal vessels | ||||
| L4140 | Endarterectomy of renal artery | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1880 | Laparoscopic cholecystectomy with perioperative cholangiogram | Xmajor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.8 | Spine | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| 11.7 | Other organs (mainly digestive) | ||||
| J3200 | Repair of bile duct | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W7400 | Reconstruction of one or two ligaments not elsewhere specified | Major | |||
| 16.10 | Knee | ||||
| W8200 | Arthroscopic Meniscectomy (Including Debridement) ? Unilateral | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| 25022 | Stellate ganglion block (local anaesthetic) +/- Image Guidance | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2310 | Anterior +/- posterior colporrhaphy (including primary repair of enterocele) (including cystoscopy) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0287 | Robotic assisted partial nephrectomy - bilateral | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1994 | Revision Replacement Of Ascending Aorta And Arch +/- Aortic Root With Frozen Elephant Trunk Procedure | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2220 | Laparoscopic repair of femoral hernia requiring mesh - bilateral | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA401 | Vocal pitch reduction surgery for gender affirmation including Adams apple augmentation +/- implant +/- laser assisted voice adjustment | Major | |||
| GA513 | Distal Tissue Grafts For Vaginoplasty For Gender Affirmation | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0221 | Nephroureterectomy - bilateral | Xmajor | |||
| 12.2 | Ureter | ||||
| M3000 | Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0420 | Triple fusion of joints of hindfoot without autogenous graft | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| B3310 | Drainage of breast abscess including haematoma and seroma | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W2810 | Repair of non-union of clavicle | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E2100 | Repair of pharynx | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4451 | Balloon kyphoplasty – single level | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| 8.9 | Heart – cardiology | ||||
| K4910 | Percutaneous transluminal angioplasty of coronary artery(ies) with stent insertion | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 12.3 | Bladder | ||||
| M5280 | Revision retropubic suspension of neck of bladder (including colposuspension and cystoscopy) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| T7990 | Revision of open or arthroscopic rotator cuff repair +/- decompression | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G4520 | Diagnostic enteroscopy | Intermediate | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| B3220 | Core biopsy of lesion of breast ? unilateral | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0830 | Correction of congenital atresia of choana (including endoscopic) | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.1 | Investigations | ||||
| 9 | Vascular system | ||||
| 9.3 | Renal vessels | ||||
| 9.6 | Non-specific | ||||
| L7580 | Repair arteriovenous fistula | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2500 | Primary posterior fusion +/- decompression +/- discectomy - lumbar region (1 or 2 levels) including spinal cord monitoring | Complex | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8700 | Ligation/stripping of long and short saphenous veins (including local excision/multiple phlebectomy) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0285 | Trapezio-metacarpal joint surface replacement | Major | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H2180 | Fibreoptic colonoscopy and recanalisation of tumour | Major | |||
| 9 | Vascular system | ||||
| 9.1 | Head and neck | ||||
| L2930 | Bypass carotid artery from the arch | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G1460 | Endoscopic mucosal resection of high-grade dysplasia in Barrett's oesophagus | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G2591 | Revision of anti-reflux operations with laparoscopic insertion of magnetic band (as sole procedure) | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P3196 | Robotic assisted excision of recto-vaginal endometriosis including disc resection of rectum, +/-ureterolysis | Extra Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7920 | Dilatation of urethra (including cystoscopy) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2225 | Laparoscopic repair of femoral hernia not requiring mesh | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T7050 | Lengthening of tendon(s), or open tenotomy | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 3.9 | Neurophysiological procedures | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA503 | Phalloplasty Stage 2 (Using Pedicelled Urethral Reconstruction) For Gender Affirmation (Including Cystoscopy) | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.8 | Neck | ||||
| T8610 | Biopsy/sampling of cervical lymph nodes | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1300 | Transluminal operations on pulmonary artery | Xmajor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| X1410 | Total exenteration of pelvis | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H2503 | Therapeutic sigmoidoscopy with snare loop biopsy or excision of lesion | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| J9902 | Cytoreductive surgery for Colorectal Peritoneal Carcinomatosis (2-3 distinct precedures) with intraperitoneal chemotherapy | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| P2730 | Colposcopy (+/- Biopsy, Polypectomy or Vulvoscopy) **REFER TO SPINE 555** | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| 4.11 | Retina | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR920 | Cyst ablation under imaging control | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1643 | Open reduction/internal fixation of either posterior wall/column or acetabulum or anterior column of acetabulum | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT213 | Planning, insertion and removal of high dose rate radioactive treatment (brachytherapy) into prostate tumour | ||||
| BT214 | Planning And Insertion Of Low Dose Rate Radioactive Treatment (Brachytherapy) Into Prostate Tumour | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6140 | Radical perineal prostatectomy, reconstruction of blader neck (including bilateral pelvic lymphadenectomy) (including cystoscopy) | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S2000 | Large island skin flap (9cm2 or more) (eg radical forearm) including closure of secondary defect | Xmajor | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8532 | Operations for recurrent varicose veins without re-exploration of groin or popliteal fossa - unilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| W7489 | Revision of posterior cruciate ligament reconstruction including autograft/allograft | Extra Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0286 | Robotic assisted nephroureterectomy - bilateral | Extra Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1001 | Robotic assisted excision of sigmoid colon | Extra Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W8370 | AUTOLOGOUS SCAFFOLD INSERTION FOR REPAIRING SYMPTOMATIC CHONDRAL KNEE DEFECTS (INCLUDING MICROFRACTURE) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2213 | Laparoscopic repair of femoral hernia not requiring mesh - unilateral | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA500 | Phalloplasty Stage 1 (Using Radial Forearm Tissue) For Gender Affirmation | Complex | |||
| GA501 | Phalloplasty Stage 1 (Using Anterolateral Thigh Tissue) For Gender Affirmation | Complex | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B2752 | Subcutaneous mastectomy | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1940 | Primary open reduction of short bone with fixation (including intra-articular) | Intermediate | |||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6420 | Excision of lesion of iris | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| F3620 | Drainage of peritonsillar abscess ('quinsy') | Minor | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.6 | Other | ||||
| A8300 | Electro-convulsive therapy | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T3910 | Excision of retroperitoneal tumour, +/-ureterolysis | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A3330 | Removal of neurostimulator from cranial nerve | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7180 | Extracapsular cataract extraction with implant - unilateral | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0284 | Total excision of trapezium and ligament reconstruction | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K4880 | Correction of anomalous coronary arteries | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S3625 | Full thickness graft, head, neck, hands and genitalia each additional 16cm2 in area | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| T6722 | Primary open lengthening of Achilles tendon | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N0500 | Bilateral excision of testes | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0980 | Deep brain stimulation | Complex | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5950 | Femoro-distal calf bypass using prosthesis +/- vein cuff/patch | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| A4280 | Intracranial infection: burr hole | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA510 | Metoidioplasty +/- Urethral Reconstruction (=/- Scrotoplasty) (Including Cystoscopy) For Gender Affirmation | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2750 | Repair of sciatic hernias | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0654 | Removal of benign lesion on head and neck (excluding scalp) which is closed by primary closure or advancement flap (excluding lipoma) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6832 | Second stage reconstruction of flexor of hand | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| S1110 | Curettage/cryotherapy of lesion of skin including cauterisation - up to three | ||||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8520 | Ligation/stripping of long or short saphenous vein (including local excision/multiple phlebectomy) - bilateral | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0110 | Toe to hand transfer (as sole procedure) including closure of secondary defect | Complex | |||
| 16.7 | Shoulder | ||||
| W9112 | Manipulation of joint (including intra-articular injection) for “Frozen Shoulder” (as sole procedure) | Minor | |||
| 16.9 | Hip, leg and pelvis | ||||
| W8800 | Diagnostic arthroscopic examination of hip joint including wash-out, with or without biopsy (as sole procedure) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.8 | Spine | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2002 | Laparoscopic repair of inguinal hernia - unilateral | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.11 | Liver | ||||
| XR610 | Transjugular intrahepatic portosystemic shunt | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W5032 | 2 stage revision of total shoulder replacement for infection - second stage | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| L1400 | Pulmonary endarterectomy | Complex | |||
| 8.8 | Heart – cardiac surgery | ||||
| K2281 | Closure of left atrial appendage (other than percutaneous) in association with other cardiac surgery | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L0200 | Closed ligation of patent ductus arteriosus | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1480 | Endoscopic exploration frontal sinus beyond frontoethmoid recess and bilateral | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| B2820 | WIDE LOCAL EXCISION OF BREAST LOCAL MOBILISATION OF GLANDULAR BREAST TISSUE TO FILL SURGICAL CAVITY | Intermediate | |||
| 7.3 | Reconstruction | ||||
| B3020 | Fat transfer, including extraction and transfer for volume adjustment following mastectomy and reconstruction (as sole procedure) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2600 | Repair of recurrent incisional hernia not requiring mesh | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| Q0220 | Laser destruction of lesion of cervix uteri (+/- colposcopy or polypectomy) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| L2560 | Percutaneous or open placement of intra-aortic balloon (including subsequent removal) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1450 | Bone flap to frontal sinus (and bilateral) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3400 | Gastrostomy | Major | |||
| 11.4 | Small intestine | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| 4.8 | Iris and anterior chamber | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W2310 | Secondary open reduction of fractured long bone and intra-medullary fixation or internal fixation for non-union/mal union – including intra-articular (including bone graft) | Xmajor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| Q0340 | Punch biopsy of cervix uteri | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B0812 | Total Thyroidectomy/Near Total Thyroidectomy +/- Microlaryngoscopy/Laryngoscopy | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0650 | Exploration of orbit (as sole procedure) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A4730 | Percutaneous cordotomy of spinal cord | Xmajor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G4410 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with insertion of prosthesis | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| XR130 | Transjugular/transfemoral plugged liver biopsy(ies) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W2100 | Primary open reduction of intra-articular fracture of long bone with internal fixation, eg proximal humerus or proximal tibia (with or without arthroscopic assistance) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2130 | Ileal or colonic replacement of ureter | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W4280 | Total Prosthetic Replacement Of Knee Joint +/- Cement +/- Patella Resurfacing - Bilateral | Complex | |||
| 16.11 | Foot | ||||
| W1040 | Osteotomy of short bone of foot (excluding hallux valgus and including internal fixation) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6020 | Resiting of Pacemaker or implantable cardioverter defibrillator (ICD) | Intermediate | |||
| 8.10 | Great Vessels | ||||
| L1810 | Repair of leaking aneurysm of ascending aorta | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2200 | Posterior decompression +/- foraminotomy - cervical region (1 or 2 levels) | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0643 | Excision of lesion of skin or subcutaneous tissue - four or more, Trunk & Limbs (excluding lipoma) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W1590 | Correction of retracted/dislocated metatarso-phalangeal joint including tendon transfer, division/realignment of bone and internal fixation | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| C8810 | Transpupillary thermotherapy for intraocular tumours | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1880 | Laparoscopically assisted left colon resection | Xmajor | |||
| 11.9 | Abdominal wall | ||||
| T2783 | Open Component Separation Technique (CST) repair for complex abdominal hernia without mesh | Extra Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2660 | Revision of decompression for central spinal stenosis | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T4300 | Laparoscopic adhesiolysis (including biopsy) | Intermediate | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7423 | Ligation of arteriovenous fistula for dialysis | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25010 | Paravertebral block up to two levels (without X-ray control) | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6771 | Focal High Intensity Focused Ultrasound of Prostate (including Cystoscopy) | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6021 | Planning & preparation for Intracranial Stereotactic Radiotherapy (SRT) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR951 | Ultrasound-guided compression repair of aneurysm (included pseudoaneurysm) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6711 | Total Gland Cryotherapy/Cryoablation Of Prostrate | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9020 | Dynamic arthrogram of joint | Intermediate | |||
| 16.9 | Hip, leg and pelvis | ||||
| W4543 | Open reduction, internal fixation and complete revision for peri-prosthetic fracture | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2230 | Posterior colporrhaphy | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA402 | Vocal Fold Muscle Reduction (VFMR) For Gender Affirmation | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K7510 | Coronary intravascular lithotripsy +/- angioplasty +/- insertion of stent | Complex | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA508 | Phalloplasty Stage 3 With Testicular Implant For Gender Affirmation | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W8230 | Arthroscopic meniscal repair | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2580 | Ureterolysis ? bilateral | Xmajor | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A2600 | Other intracranial destruction of cranial nerve | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6510 | Carpal tunnel release (open) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W1080 | Osteotomy of long bone, with/without fixation, including graft | Major | |||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| R1220 | Transvaginal removal of cerclage of cervix of gravid uterus | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1700 | Total reconstruction of eyelid - unilateral | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 20143 | Removal of implantable ECG loop recorder (including reporting) | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| M8130 | External meatotomy of urethral orifice | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E2400 | Therapeutic endoscopic operation on pharynx | Minor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0310 | Exploratory open craniotomy | Xmajor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2330 | Transabdominal repair of hiatus hernia | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A1220 | Creation of ventriculovascular anastomosis | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.4 | Muscles | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1642 | Open reduction/internal fixation of posterior rim of acetabulum | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0608 | Sentinel lymph node biopsy for melanoma | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6130 | Goniotomy (surgical treatment of glaucoma) (including topical or local anaesthetic) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| F3400 | Tonsillectomy - child (and bilateral) up to and including age 12 | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2560 | Decompression for central spinal stenosis (one or two levels) | Xmajor | |||
| 3.9 | Neurophysiological procedures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N1900 | Operation(s) on varicocele | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.5 | Conjuctiva | ||||
| C4340 | Subconjunctival injection | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| X3750 | Botulinum toxin injections to muscle | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0322 | Osteotomies (Eg Scarf And Akin) For Hallux Valgus Correction +/- Internal Fixation +/- Soft Tissue Correction - Bilateral | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.2 | Lips | ||||
| F0315 | Primary closure of cleft lip - bilateral including anterior palate | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4110 | Open excision of lesion from bladder (including cystoscopy) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T3930 | Surgical drainage of retroperitoneal abscess | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0110 | Hemispherotomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1390 | Open femoro-acetabular surgery for hip impingement | Xmajor | |||
| 9 | Vascular system | ||||
| 9.3 | Renal vessels | ||||
| L4190 | Reconstruction of renal artery(ies) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8780 | Diagnostic arthroscopic examination of joint, with or without biopsy - bilateral (not otherwise specified) (as sole procedure) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C4980 | Tension sutures | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G2110 | Oesophageal physiology studies (including pH measurement) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2780 | Repair of tricuspid valve, eg for Ebstein's disease | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| T6460 | Tendon transfer of toe – unilateral | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| M7590 | Insertion of suburethral tape sling (e.g. TOT or TVT) +/- administration of local anaesthetic by operating surgeon (including cystoscopy) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1091 | Robotic assisted pyeloplasty - bilateral | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2214 | Laparoscopic repair of recurrent femoral hernia requiring mesh - unilateral | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA515 | Orchidectomy (Removal Of Testes) For Gender Affirmation - Bilateral | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W7482 | Scaphoid lunate ligament reconstruction | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22002 | Routine electroencephalography (EEG) in child under 5 (including reporting) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| A7561 | VATS sympathectomy - bilateral | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5520 | Total pancreatectomy | Complex | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.12 | Urinary | ||||
| XR670 | Radiofrequency kidney ablation | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3500 | Partial cystectomy (including cystoscopy) | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0751 | Laparoscopic subtotal hysterectomy, +/- oophorectomy, +/- ureterolysis | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| F4040 | Suture of mouth as sole procedure | Minor | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9350 | Basilic vein transposition | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G7512 | Revision of ileostomy - local | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4910 | Closure of cystostomy | Intermediate | |||
| M5820 | Dilatation of outlet of female bladder (with cystoscopy) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0610 | Packing of cavity of nose (as sole procedure) | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7683 | Presacral sympathectomy - therapeutic | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0213 | Excision of lesion of orbit - lateral orbitomy | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| D0702 | Aural toilet (including microsuction and/or suction of exteriorised mastoid cavity) including bilateral | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W7713 | Primary stabilisation of multi-directional instability of shoulder joint +/- tendon repair | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3012 | Mastectomy and immediate reconstruction of breast using expandable prosthesis - unilateral | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G4030 | Pyloroplasty | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| T7910 | Open sub acromial decompression and rotator cuff repair +/- excision of distal clavicle | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K6700 | Pericardiectomy | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| C0630 | Decompression of orbit | Major | |||
| 4.3 | Lacrimal system | ||||
| C2920 | Insertion of canalicular or punctal plugs | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W6202 | Partial fusion of wrist | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4410 | Litholapaxy (including cystoscopy) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2010 | Primary repair of inguinal hernia ? bilateral | Major | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L8110 | Creation of peritoneovenous shunt (Levine/Denver) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR380 | Embolisation of aneurysm | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| B2222 | Adrenalectomy - bilateral (open) | Xmajor | |||
| 9 | Vascular system | ||||
| 9.5 | Ileo-femoral vessels | ||||
| L5922 | Femoro-popliteal bypass using prosthesis | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| T7915 | Arthroscopic rotator cuff repair greater than 2cm | Xmajor | |||
| 16.11 | Foot | ||||
| W4410 | Total prosthetic replacement of ankle joint | Xmajor | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A2220 | Puncture of cistern of brain | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T5250 | Endoscopic plantar fascia release | Intermediate | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7520 | Repair of acquired arteriovenous fistula | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0810 | Excision of lesion of external auditory canal | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G2810 | Partial gastrectomy and excision of surrounding tissue | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W6702 | Secondary open reduction of dislocation of small joint | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR303 | Additional management of brain arteriovenous malformation (per additional intervention) | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| C5432 | Conventional retinal surgery (may include scleral buckling, injection of gas, drainage and retinopexy) | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M5220 | Retropubic suspension of neck of bladder (including colposuspension)(including cystoscopy) | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0633 | Excision of lesion of skin or subcutaneous tissue - up to three, Trunk & Limbs (excluding lipoma) | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0820 | Reconstruction of external auditory canal | Xmajor | |||
| 5.5 | Nasal sinuses | ||||
| E1500 | Operation(s) on sphenoid sinus (including endoscopic) and bilateral | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2913 | Reconstruction of breast using latissimus dorsi including implantation of prosthesis (including delayed reconstruction) | Xmajor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR935 | Insertion/removal of vena cava filter | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A5300 | Drainage of spinal canal (including insertion of shunt) | Xmajor | |||
| 3.8 | Other procedures | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N1340 | Biopsy of testis | Minor | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7422 | Creation of arteriovenous fistula for dialysis | Intermediate | |||
| L9730 | Isolated limb perfusion | Xmajor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.1 | Globe and orbit | ||||
| 4.4 | Muscles | ||||
| C3530 | Surgical correction of squint with adjustable sutures | Xmajor | |||
| 4.9 | Lens | ||||
| C7100 | Extracapsular cataract extraction without implant - bilateral | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3713 | Complex primary total hip replacement including bone grafting or femoral osteotomy | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0310 | Multiple procedures on forefoot, distal to and including the tarsometatarsal joints, which involves at least two distinct procedures not intrinsic to each other - bilateral | Extra Major | |||
| 16.12 | External fixation/traction | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1540 | Exploration of entire middle ear course of VII | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 16.8 | Elbow | ||||
| T8050 | Surgical release of humeral epicondylitis (lateral or medial) (eg “Tennis Elbow”) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| D2420 | Insertion of cochlear implant - unilateral | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| B1690 | Mediastinal parathyroidectomy with sternotomy | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4850 | Therapeutic bronchoscopy for removal of foreign body | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D2040 | Diagnostic tympanotomy (as sole procedure) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.7 | Teeth | ||||
| F0910 | Surgical removal of impacted/buried tooth/teeth | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W0700 | Excision of ectopic bone | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25140 | Intrathecal neurolysis | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 20142 | Insertion of implantable ECG loop recorder (including reporting) | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| A2781 | Laparoscopic vagotomy/seromyotomy | Major | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L6710 | Biopsy of artery (including temporal) (as sole procedure) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| B2232 | Adrenalectomy - unilateral (open) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3942 | Removal of total hip replacement and creating a pseudarthrosis | Xmajor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.5 | Vulva/labia | ||||
| P0510 | Simple vulvectomy | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1360 | Percutaneous insertion of nephrostomy tube | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| D2610 | Operation(s) on endolymphatic sac | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T3080 | Laparotomy and repair of multiple visceral trauma | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K3210 | Closed mitral valvotomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0460 | Complex procedure to mid foot or hind foot without autogenous bone graft (osteotomy/fusion +/? tendon transfers) | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K3580 | Trans catheter aortic valve implantation (TAVI) without percutaneous insertion of a cerebral protection device | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 25000 | Incision and drainage (not elsewhere covered) | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L0230 | VATS closure of patent ductus arteriosus | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C4730 | Removal of corneal suture | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| E6300 | Diagnostic mediastinoscopy | Intermediate | |||
| 8.8 | Heart – cardiac surgery | ||||
| K2602 | Minimally invasive replacement of aortic valve | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W0950 | Radical clearance of sarcoma of trunk or limbs, +/- amputation or insertion of prosthesis | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.3 | Cervix uteri | ||||
| BT341 | Planning for insertion and removal of a radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| V0382 | Total petrosectomy (for tumour) | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A2500 | Intracranial transection of cranial nerve | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6810 | Neurolysis and transposition of peripheral nerve (excludes carpal tunnel release) | Intermediate | |||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G0920 | Oesophagocardiomyotomy (Heller's operation) | Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P2100 | Reconstruction of vagina | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6900 | Revision of release of peripheral nerve | Major | |||
| 16.11 | Foot | ||||
| W0300 | Multiple Procedures On Forefoot, Distal To And Including The Tarsometatarsal Joint, Which Involves At Least Two Distinct Procedures Not Intrinsic To Each Other - Unilateral | Major | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3100 | Laparoscopic biliary gastric bypass | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8550 | Block dissection of inguinal lymph nodes | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7124 | Phacoemulsification of cataracts, without lens implant - bilateral (including topical or local anaesthetic) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W7484 | Multiple ligament reconstruction | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.3 | Trachea | ||||
| E4100 | Insertion of voice prosthesis (TOF) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T4302 | Open adhesiolysis (including biopsy) | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A1240 | Creation of ventriculoperitoneal shunt | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.9 | Neurophysiological procedures | ||||
| 22003 | Sleep Electroencephalography (EEG) | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W0850 | Partial excision of bone (including exostoses) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5710 | Ablation of atrio-ventricular junction (including mapping) | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.4 | Small intestine | ||||
| G6100 | Bypass of jejunum | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S4812 | Insertion of skin expander into tissue (not related to breast reconstruction) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| XR430 | Renal angioplasty, +/- insertion of stent | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M5630 | Therapeutic injection into bladder neck for treatment of stress incontinence (periurethral bulking agents), including cystoscopy | Intermediate | |||
| 12.6 | Genitalia | ||||
| N1352 | Laparoscopy for impalpable testis | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C3960 | Excision of pterygium | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.8 | Elbow | ||||
| W7850 | Open arthrolysis of elbow | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0800 | Excision of transverse colon | Xmajor | |||
| 11.7 | Other organs (mainly digestive) | ||||
| J6100 | Open drainage of lesion of pancreas | Major | |||
| 11.9 | Abdominal wall | ||||
| T2830 | Resuture of previous incision in abdominal wall (“burst abdomen”) | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.10 | Gastrointestinal | ||||
| XR590 | Percutaneous gastrojejunostomy (As sole procedure) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.8 | Neck | ||||
| T9400 | Operations on branchial cyst | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| W3180 | Free composite (ie including bone) vascularised grafts | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K3100 | Open valvotomy | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W1700 | Shelf augmentation of acetabulum, eg Wainwright or Trillat | Xmajor | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| B2831 | Re-excision of lesion of breast if resection margins are not clear with local mobilisation | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M7030 | Limited/single core transrectal needle biopsy of prostate +/- ultrasound guidance | Minor | |||
| 12.6 | Genitalia | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W9050 | Shoulder hydrodistension +/- image guidance | Minor | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9181 | Removal of Portacath/vasoport unit | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6820 | Secondary repair or reconstruction of extensor of hand/forearm | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 13 | Pregnancy and confinement | ||||
| 13.1 | Pregnancy and confinement | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.5 | Vulva/labia | ||||
| P0910 | Biopsy of lesion of vulva | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| N1101 | Correction of hydrocele(s) - bilateral | Intermediate | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.1 | Bone Marrow | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0710 | Forequarter amputation | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7940 | Internal urethrotomy (including cystoscopy +/- dilataion) | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G8080 | Small bowel capsule endoscopy (including interpretation and evaluation) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2511 | Excision of ureterocele (with or without ureteric reimplantation) - bilateral | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2562 | Decompression for central spinal stenosis (three or more levels) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W5920 | Fusion of first metatarsophalangeal joint with bone grafting +/- internal fixation (as sole procedure) | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K0960 | Minimally invasive endoscopic repair of atrial septal defects (ASD) via mini-thoracotomy | Complext | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W5031 | 2 Stage Revision of Total Shoulder Replacement For Infection - First Stage | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5530 | Closure of anal fistula using a suturable bioprosthetic or synthetic plugs +/- image guidance | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S6042 | Scar Revision over 5cm - Head & Neck | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1645 | Open reduction/internal fixation plus bone graft symphysis pubis | Complex | |||
| 16.6 | Hand | ||||
| W0512 | Interpositional silastic arthroplasty of metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint ? single digit | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A4850 | Implantation/removal of intrathecal drug delivery system | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W2502 | Closed reduction of fracture of long bone, including cast or percutaneous K-wires | Intermediate | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7123 | Phacoemulsification of cataract, without lens implant - unilateral (including topical or local anaesthetic) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N3032 | Revision of Circumcision | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2140 | Reconstruction using stomach pull up following pharyngolaryngectomy | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2003 | Repair Of Inguinal Hernia Requiring Removal Of Previously Inserted Mesh | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7215 | Paediatric Cataract Involving Lens Aspiration And Implant Bilateral | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9000 | Open removal of thrombus from vein | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X7001 | Planning And Delivery Of Intraoperative Radiation Therapy (IORT) | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3039 | Removal And Reinsertion Of Existing Prosthesis Into The Breast (Including Capsulectomy) - Bilateral | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2782 | Minimally Invasive Component Separation Technique (CST) Requiring Mesh | Extra Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q1111 | Manual vacuum aspiration of retained products of conception | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| E2500 | Diagnostic nasolaryngopharyngoscopy +/- biopsy, +/- cautery as sole procedure | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2300 | Repair of recurrent femoral hernia | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1910 | Middle ear polypectomy | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25012 | Sacral root block (under X-ray control) | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S4740 | Drainage of large subcutaneous abscess/haematoma | Minor | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6011 | Planning and preparation for the delivery of superficial radiotherapy with imaging, dosimetry and calculation using orthovoltage | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.4 | Urethra | ||||
| M7930 | Endoscopic dilation of urethra using drug coated balloon (+/- fluoroscopy) | Minor | |||
| 12.6 | Genitalia | ||||
| N2783 | Correction Of Chordee | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W1641 | Osteotomy of short bone of hand (including fixation and bone grafting) | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.3 | General procedures | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR960 | Percutaneous thermal coagulation of mass | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6820 | Pericardiocentesis | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| 2.2 | Cranium | ||||
| V0180 | Surgery for craniostenosis (more than one suture) | Xmajor | |||
| 9 | Vascular system | ||||
| 9.2 | Thoracic vessels | ||||
| L1910 | Elective repair of aneurysm of ascending aorta | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| B1800 | Thymectomy for myasthenia gravis/thymoma | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W7921 | SURGICAL CORRECTION OF HALLUX VALGUS USING MINIMAL ACCESS TECHNIQUES - BILATERAL | major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P3197 | Robotic assisted excision of recto-vaginal endometriosis including bowel resection (including formation of stoma) +/- hysterectomy, +/-ureterolysis | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| T6410 | Tendon transfer of hand – multiple (eg for radial nerve injury) | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K4100 | Bypass for coronary artery(ies) including harvesting of grafts and endarterectomy | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0310 | Reconstruction of external ear for anotia/microtia using cartilage | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2700 | Subcutaneous mastectomy with immediate implant | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.12 | External fixation/traction | ||||
| W2930 | Removal of skeletal traction from bone | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K0980 | Septal myectomy | Complex | |||
| 8.10 | Great Vessels | ||||
| L1993 | Replacement Of Ascending Aorta And Arch +/- Aortic Root With Frozen Elephant Trunk Procedure | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2413 | Laparoscopic repair of umbilical/paraumbilical hernia not requiring mesh | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.11 | Retina | ||||
| C8241 | Photodynamic therapy to the retina (PDT) - Bilateral | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N2781 | Lue's procedure for Peyronie's disease | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7520 | Lens implant/exchange | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6700 | Release of entrapment of peripheral nerve | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M5300 | Vaginal operations to support outlet of female bladder (including cystoscopy) | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1230 | Curettage/cryotherapy of lesion of eyelid | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S2220 | Neurovascular island flap | Xmajor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J3100 | Open introduction of prosthesis into bile duct | Major | |||
| 11.9 | Abdominal wall | ||||
| T1900 | Simple excision of inguinal hernial sac (herniotomy) - unilateral | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K1850 | Revision placement of valve to cardiac conduit | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6160 | Complex glaucoma surgery (including anti-metabolites/insertion of seton devices) (including topical or local anaesthetic) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T8100 | Open biopsy of muscle or soft tissue lesion | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| E4722 | Thoracotomy and closure of broncho-pleural fistula | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T6000 | Repeat excision of ganglion | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| T1480 | Insertion of pleuro-peritoneal shunt | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR936 | Insertion of guidewire and/or marker into breast lesion under imaging control | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0400 | Repair of liver (including therapeutic laparoscopic operations on liver) | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| S0632 | Excision of lesion of skin or subcutaneous tissue - up to three, Head & Neck (excluding lipoma) | Minor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W2380 | Locked intramedullary nailing of fractured long bone | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K0900 | Repair of complete atrioventricular septal defect | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25100 | Coeliac plexus block, splanchnic nerve block, hypogastric block - diagnostic +/- Image Guidance | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W7500 | Prosthetic Open Repair Of Ligament Not Elsewhere Specified | Major | |||
| 16.6 | Hand | ||||
| T5203 | Dupuytren’s fasciectomy single digit with proximal interphalangeal joint | Intermediate | |||
| 16.9 | Hip, leg and pelvis | ||||
| 16.11 | Foot | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2310 | Open ureterolithotomy (including cystoscopy) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1010 | Radical mastoidectomy (including meatoplasty) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4714 | Therapeutic injection into bladder wall (including cystoscopy) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| L2720 | Endovascular aneurysm repair (EVAR) of suprarenal aorta, with insertion of fenestrated graft (up to two orifices) | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| W0951 | Radical clearance of sarcoma of head and neck necessitating flap reconstruction | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W7900 | Excision Of Medial Eminence First Or Fifth Metatarsal Head With Soft Tissue Repair (Bunionectomy) | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V0930 | Closed reduction of fracture of zygomatic complex of bones | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N1100 | Correction of hydrocele(s) ? unilateral | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1220 | Caldwell-Luc procedure | Intermediate | |||
| 5.7 | Larynx and trachea | ||||
| E3010 | Glottoplasty (e.g.vocal pitch change surgery) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5750 | Laparoscopic distal pancreatectomy | Xmajor | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| T8780 | Sentinel node biopsy (except where otherwise listed) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W5210 | Revision of unicompartmental knee replacement | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| BT253 | Low energy contact X ray brachytherapy (the Papillon technique) for early stage rectal cancer | ||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| C6181 | Laser suture lysis (including topical or local anaesthetic) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q1281 | Removal and/or replacement of an embedded / migrated Mirena coil (as sole procedure) | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T7232 | Percutaneous release of constriction of sheath of tendon (e.g. trigger finger) | Intermediate | |||
| 16.10 | Knee | ||||
| W5810 | Patella resurfacing (as sole procedure) | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| V5487 | Pedicle based dynamic semi-rigid stabilisation procedure (e.g accuflex) | ||||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6005 | Inverse planning and preparation for the delivery of intensity modulated radiotherapy (IMRT), including adaptive IMRT | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W3751 | Customised unilateral hip replacement | Extra Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4070 | Stabilisation of pars defect + /- instrumentation +/- bone graft +/- spinal monitoring - **REFER TO SPINE 578 ** | Extra Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| B2224 | Robotic assisted adrenalectomy - bilateral | Extra Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT215 | Planning for insertion of low dose rate radioactive treatment (brachytherapy) into prostate tumour | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4170 | Distraction of traditional spinal growing rods for idiopathic juvenile scoliosis including spinal cord monitoring and imaging | Intermediate | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| T9021 | Injection of magnetic lymphatic tracer and subsequent sentinel node mapping +/- sampling for breast cancer | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.8 | Other procedures | ||||
| V5260 | Myelogram | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR939 | Insertion of radio- frequency identification tag for non-palpable breast lesions under imaging control | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.10 | Great Vessels | ||||
| L1980 | Elective repair of aneurysm of arch of aorta | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J0320 | 2 stage associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure ? first stage | Extra Major | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| P3195 | Robotic assisted excision of recto-vaginal endometriosis including rectal shave, +/-ureterolysis | Major | |||
| 14.4 | Vagina/perineum | ||||
| P2430 | Robotic assisted sacrocolpopexy +/- ureterolysis, using mesh | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.2 | Bone (non-specific) | ||||
| W7081 | Radiofrequency ablation of bone metastasis +/- bone cement +/- spinal cord monitoring using image guidance | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| L2361 | Thoracotomy and division of aberrant subclavian artery and re-implantation with interposition graft | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J1822 | Laparoscopic cholecystectomy with exploration of common bile duct | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA514 | Vulvoplasty (Creation Of Vulva) For Gender Affirmation | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.1 | External ear | ||||
| D0280 | Removal of multiple boney exostoses EAC | Intermediate | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.9 | Lens | ||||
| C7125 | Ultrasound phacoemulsification of cataracts, with lens implant - bilateral (including topical or local anaesthetic) | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W0120 | Pollicisation of finger for thumb reconstruction | Complex | |||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L1940 | Open infrarenal abdominal aortic aneurysm tube graft | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1542 | Closure of colostomy | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6600 | Release of entrapment of deeply placed peripheral nerve | Intermediate | |||
| 16.9 | Hip, leg and pelvis | ||||
| W3717 | Minimally Invasive Hip Replacement - Unilateral | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K5283 | Complex Cox lesion set maze operation | Complex | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR360 | Embolisation of vascular mass (including uterine embolisation) | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3700 | Repair of bladder (including cystoscopy) | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| B2744 | Modified radical mastectomy including lymph node clearance | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.4 | Nerve roots | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0463 | Complex Procedure To Mid Foot And Hindfoot Without Autogenous Bone Graft (Osteotomy/Fusion +/- Tendon Transfers/Fixation) | Complex | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.3 | Lacrimal system | ||||
| C2910 | Puncto-canaliculoplasty | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3400 | Open total cystectomy (with construction of intestinal conduit or bladder) | Complex | |||
| 7 | Breast | ||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| B2223 | Laparoscopic Adrenalectomy - Bilateral | Xmajor | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B3013 | Mastectomy and immediate reconstruction of breast using fixed prosthesis - unilateral | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| 25110 | Coeliac plexus block, splanchnic nerve block, hypogastric block - therapeutic +/- Image Guidance | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.4 | Flaps and free skin grafts | ||||
| S3500 | Split autograft of skin, trunk and limbs ? up to 25cm2 in area | Intermediate | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| B3593 | Microdochectomy or mammodochectomy (Hadfield’s procedure) | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.6 | Throat | ||||
| F3650 | Arrest of haemorrhage following tonsillectomy/adenoidectomy | Intermediate | |||
| 9 | Vascular system | ||||
| 9.8 | Lymphatic system | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0220 | Nephroureterectomy - unilateral | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W6703 | Secondary open reduction of dislocation of large joint | Intermediate | |||
| 16.11 | Foot | ||||
| T6462 | Excision Or Partial Excision Of Interphalangeal Joint Of Lesser Toe With Tendon Transfer | Intermediate | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| XR916 | Surgical removal of cuffed central venous catheter - tunnelled (X-ray guided) | Minor | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| T1030 | Video-assisted thoracoscopic surgery (VATS) assisted pleurodesis / pleurectomy | Major | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.6 | Cornea | ||||
| C4810 | Removal of superficial corneal foreign body | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V3120 | Transthoracic/antero-lateral excision of intervertebral disc +/? fusion Including Spinal Cord Monitoring | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.6 | Hand | ||||
| W7485 | Small joint (eg interphalangeal/metacarpo-phalangeal joint) ligament reconstruction | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2102 | Laparoscopic repair of recurrent inguinal hernia - unilateral | Intermediate | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.3 | Angioplasty | ||||
| XR290 | Cerebral angioplasty with or without insertion of metallic stent | Complex | |||
| 17.13 | Other | ||||
| XR967 | CT guided thermocoagulation of osteoid osteoma | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W2500 | Closed reduction of fracture of long bone with external fixation (excluding fixation by cast or percutaneous K-wires) | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.2 | Drainage | ||||
| XR180 | Ultrasound guided drainage of fluid collection | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W6014 | Primary arthrodesis of knee joint with or without graft and with or without internal fixation | Major | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
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| 12.6 | Genitalia | ||||
| N0630 | Laparoscopic orchidectomy | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
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| 5.5 | Nasal sinuses | ||||
| E1460 | Trephining of frontal sinus and bilateral | Minor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W1320 | Osteotomy of proximal femur | Xmajor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W6019 | Ankle syndesmosis reconstruction | Complex | |||
| T6762 | Repair of tendon of foot - flexor | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6580 | Carpal tunnel release (open) - bilateral | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.13 | Amputation | ||||
| X0820 | Partial amputation of digit | Intermediate | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9115 | Implantation of port device (PowerPort) | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M3510 | Diverticulectomy of bladder | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A7011 | Trial of neurostimulator to peripheral nerve (as sole procedure) not at time of permanent implant | Intermediate | |||
| 16.9 | Hip, leg and pelvis | ||||
| W3715 | Hip resurfacing arthroplasty | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K5380 | Repair of ventricular aneurysm | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W5723 | Excision reconstruction of large joint | Major | |||
| 16.10 | Knee | ||||
| W7480 | Posterior cruciate ligament reconstruction | Xmajor | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L7110 | Percutaneous transluminal angioplasty of artery, +/- insertion of stent | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6100 | Open excision of prostatatic adenoma | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2120 | Reduction of dislocation of temporomandibular joint | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.4 | Nerves | ||||
| A2953 | Excision of acoustic neuroma (vestibular schwannoma) - tumours more than 2.5cm or compressing brain stem (performed by single surgeon) | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 3.7 | Other nerve blocks | ||||
| A7300 | Radiofrequency (including pulsed denervation), cryoprobe or phenol for permanent lesion of named peripheral nerve +/- image guidance | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0900 | Excision of left hemicolon | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.7 | Other nerve blocks | ||||
| A7302 | Continuous nerve block +/- image guidance (as sole procedure) | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| A2781 | Laparoscopic vagotomy/seromyotomy | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V4140 | Removal of posterior spinal implant | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1040 | Simple mastoidectomy | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G3800 | Open operations on stomach not elsewhere classified | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.1 | Biopsy | ||||
| XR120 | CT/MRI guided biopsy(ies) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2300 | Revisional posterior decompression +/– foraminotomy (cervical region) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6750 | Cubital tunnel release (endoscopic) Bilateral (without transposition) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K5110 | Angioscopy | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G4371 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with therapy for acutely bleeding ulcer or varices | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.8 | Iris and anterior chamber | ||||
| C6170 | Goniosynechialysis or goniopuncture (with laser or operatively) (including topical or local anaesthetic) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| BT252 | Insertion and removal of radioactive agent (brachytherapy) into rectal tumour | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| BT282 | Insertion and removal of radioactive agent (brachytherapy) into the vagina | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D2070 | Transtympanic steroid injection (including topical or local anaesthetic) | Minor | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.2 | Stem Cell | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.3 | Inner ear | ||||
| E2880 | Epley manoeuvre (code for specialist use only) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2340 | Transabdominal repair of diaphragmatic hernia (excluding hiatus hernia) | Complex | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.2 | Stem Cell | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| Q5450 | Laparoscopic hysteropexy (including sacrohysteropexy) using mesh +/- ureterolysis | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0380 | Fusion Of First Metatarsophalangeal Joint - Bilateral | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G1421 | Endoscopic focal ablation of dysplasia in Barrett's oesophagus | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T6910 | Tenolysis, of extensor, not otherwise specified | Intermediate | |||
| 16.8 | Elbow | ||||
| W5502 | Interposition arthroplasty of elbow | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25020 | Intravenous regional sympathetic block (guanethidine block) - 1 injection | Minor | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.12 | Urinary | ||||
| XR630 | Percutaneous nephrostomy | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| A7682 | Presacral sympathectomy - diagnostic | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.4 | Nerves | ||||
| A6711 | Cubital tunnel release (open) bilateral (without transposition) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| J9907 | Cytoreductive surgery for Ovarian Malignancies excluding intraperitoneal chemotherapy | Complex | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| BT342 | Insertion and removal of a radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | ||||
| BT253 | Low energy contact X ray brachytherapy (the Papillon technique) for early stage rectal cancer | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| J9903 | Cytoreductive surgery for coloretal peritoneal carcinomatosis (4-6 distinct procedures) with intraperitoneal chemotherapy | Complex | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| X4120 | Removal of Tenckhoff catheter | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| J9908 | Cytoreductive Surgery For Stage iii Epithelial Ovarian Malignancies Including Heated Intraperitoneal Chemotherapy (Hipec) | Complex | |||
| 9 | Vascular system | ||||
| 9.7 | Varicose veins | ||||
| L8550 | Bioadhesive Closure Of Varicose Veins Using Cyanoacrylate - Unilateral | Intermediate | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| G8085 | THERAPEUTIC OESOPHAGO-GASTRO-DUODENOS (OGD)&IMMEDIATE FLEXIBLE SIGMOIDOSCOPY | INTERMEDIATE | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2031 | Arthroplasty of temporomandibular joint bilateral | Major | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6015 | Planning and preparation for the delivery of high dose brachytherapy (not otherwise specified) | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.1 | Oesophagus | ||||
| G2332 | Laparoscopic Insertion of magnetic band for gastro-oesophageal reflux disease (LINX) | Major | |||
| 7 | Breast | ||||
| 7.1 | Excision/biopsy codes | ||||
| B2800 | Excision of breast lump/fibroadenoma | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0103 | Robotic assisted Oesophagectomy/Oesophagogastrectomy with anastomosis in chest | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0321 | MRI-GUIDED FOCUSED ULTRASOUND (MRGFUS) THALAMOTOMY FOR ESSENTIAL TREMOR | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3371 | Laparoscopic colectomy +/- stoma | Extra Major | |||
| 11.9 | Abdominal wall | ||||
| T2017 | Laparoscopic repair of inguinal hernia not requiring mesh - bilateral | Intermediate | |||
| T2020 | Laparoscopic repair of recurrent inguinal hernia not requiring mesh - bilateral | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA203 | Excision Of Gonad From Pelvis For Gender Affirmation | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W4212 | Minimally Invasive Knee Replacement +/- Cement +/- Patella Resurfacing - Unilateral | Complex | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.3 | Tongue | ||||
| F2640 | Freeing of adhesions of tongue | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N2710 | Excision of lesion of penis | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6400 | Repair of peripheral nerve | Intermediate | |||
| 9 | Vascular system | ||||
| 9.4 | Abdominal vessels | ||||
| L1680 | Axillo-bifemoral bypass | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.7 | Video assisted thoracic surgery (VATS) | ||||
| E6200 | VATS excision lesion of mediastinum including thymectomy | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8700 | Diagnostic arthroscopic examination of joint, with or without biopsy (not otherwise specified) (as sole procedure) | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5043 | Primary repair of low congenital anorectal anomaly | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0321 | Osteotomies (Eg Scarf And Akin) For Hallux Valgus Correction +/- Internal Fixation +/- Soft Tissue Correction - Unilateral | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.9 | Abdominal wall | ||||
| T2110 | Repair of recurrent inguinal hernia - bilateral | Xmajor | |||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| H2003 | Therapeutic colonoscopy with snare loop biopsy or excision of lesion | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.8 | Major vessels | ||||
| L7980 | Repair of wound of major artery or vein of abdomen (including aorta and vena cava) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.5 | Prostate | ||||
| M6182 | Laparoscopic radical prostatectomy, reconstruction of bladder neck including bilateral pelvic lymphadenectomy (including cystoscopy) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | ||||
| W8380 | Therapeutic arthroscopy operation on articular cartilage (other than W8200) - bilateral (as sole procedure) | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.13 | Other | ||||
| XR962 | Percutaneous chemical ablation of tumour - ultrasound guided | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.7 | Teeth | ||||
| F0950 | Surgical removal of complicated buried roots | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0380 | Laparoscopic upper or lower pole heminephrectomy | Complex | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T2781 | Repair of epigastric hernia | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25011 | Paravertebral block up to two levels (under X-ray control) | Minor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0880 | Hysterectomy with excision / biopsy and/or removal of omentum and uterine adnexa for ovarian malignancy +/- ureterolysis | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6180 | Excision of lesion of major nerve | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5520 | Laying open of high anal fistula (fistulotomy) (including sigmoidoscopy) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T7110 | Tenosynovectomy | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| H5680 | Excision of pressure sore excluding repair | Intermediate | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2989 | Mastectomy followed by immediate Deep Inferior Epigastric Flap (DIEP) reconstruction - unilateral | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.2 | Suspension | ||||
| M5220 | Retropubic suspension of neck of bladder (including colposuspension)(including cystoscopy) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| E1780 | Diagnostic endoscopy of sinus and bilateral (as sole procedure) | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S4212 | Debridement and primary suture of wound without involvement of deeper tissue (skin and subcutaneous fat only) - Head and Neck | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V2020 | Prosthetic replacement of temporomandibular joint | Xmajor | |||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1450 | Parathyroidectomy | Xmajor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.4 | Vagina/perineum | ||||
| P1400 | Incision of introitus of vagina | Minor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F4600 | Incisional drainage of abscess or haematoma of salivary glands (ie including submandibular, parotid and sublingual glands) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2800 | Replacement of pulmonary valve (including valvuloplasty/valvotomy) | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.9 | Hip, leg and pelvis | ||||
| W1911 | Core decompression of hip | Major | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.1 | Brain | ||||
| A0310 | Stereotactic biopsy of lesion or tissue of brain | Complex | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N1910 | Laparoscopic varicocelectomy | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.1 | Investigations | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| X4112 | Percutaneous insertion of Tenckhoff catheter | Minor | |||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C2220 | Biopsy of lesion of eyelid | Minor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K1180 | Endovascular closure of perimembranous ventricular septal defect | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.5 | Sympathetic nerves | ||||
| 25020 | Intravenous regional sympathetic block (guanethidine block) - 1 injection | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.5 | Bronchi/lungs/pleura | ||||
| E5705 | Thoracotomy pleurectomy/pleurodesis +/- ligation of bullae for pneumothorax | Xmajor | |||
| 9 | Vascular system | ||||
| 9.6 | Non-specific | ||||
| L9180 | Insertion of implantable central venous port (portacath) e.g Port-a-Cath under image guidance | Intermediate | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| S1510 | Needle/tru-cut biopsy of muscle (as sole procedure) | ||||
| 4 | Eye and orbital contents | ||||
| The benefit for cataract removal by the various approaches includes subconjunctival injection and
injection into the anterior chamber where required. These should not be charged separately. When it is necessary to convert a phakoemulsification into an extra capsular extraction this should be charged as a single procedure. Retrobulbar injection. This code is for therapeutic retrobulbar injection. It is not for anaesthesia during cataract surgery. Removal of sutures. This code is for use after keratoplasty only. We do not cover blepharoplasty and this should not ever be coded as correction of ptosis/eyelid reconstruction. |
|||||
| 4.2 | Eyebrow and lid | ||||
| C1010 | Excision of lesion of eyebrow | Minor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6300 | Graft to peripheral nerve | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| A8460 | Static single measurement of muscle compartment pressures (Including reporting) | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0300 | Sub-total oesophagectomy with anastomosis in neck | Complex | |||
| 8.2 | Chest wall | ||||
| T0110 | Thoracoplasty | Xmajor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.2 | Ureter | ||||
| M2280 | Open correction vesicoureteric reflux-bilateral | Xmajor | |||
| 12.5 | Prostate | ||||
| M7020 | Transrectal sextant needle biopsy of prostate with ultrasound guidance | Minor | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.7 | Larynx and trachea | ||||
| E2950 | Laryngofissure and cordectomy of vocal cord | Major | |||
| 7 | Breast | ||||
| 7.4 | Other | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.6 | Genitalia | ||||
| N2620 | Partial amputation of penis | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | ||||
| E4800 | Therapeutic bronchoscopy (including laser, cryotherapy, lavage, snare, dilatation of stricture, insertion of stent) | Minor | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
|||||
| 17.4 | Embolisation | ||||
| XR302 | Endovascular management of brain arteriovenous malformation (including 2 separate interventions) | Complex | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.8 | Major vessels | ||||
| L7710 | Creation of portocaval shunt | Complex | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.5 | Vulva/labia | ||||
| P0310 | Excision of Bartholin gland | Intermediate | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0110 | Reconstructive cranioplasty | Xmajor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.9 | Heart – cardiology | ||||
| K6040 | Removal of pacing system with bypass | Complex | |||
| 18 | Chemotherapy | ||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
|||||
| 18.0 | Chemotherapy | ||||
| X0001 | Clinical supervision and planning for the delivery of chemotherapy and/or systemic anti-cancer therapy for 0-7 Days | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J5900 | Anastomosis of pancreatic duct (to another viscus) | Xmajor | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.5 | Mouth cavity | ||||
| F4050 | Graft of skin or mucosa to mouth | Intermediate | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.5 | Nasal sinuses | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.7 | Other organs (mainly digestive) | ||||
| J6180 | Drainage of pancreatic abscess | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.8 | Major vessels | ||||
| L7040 | Open cannulation of intra abdominal artery for infusion chemotherapy | Major | |||
| 11.9 | Abdominal wall | ||||
| T2500 | Open repair of incisional hernia not requiring mesh | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W8280 | Arthroscopic meniscectomy (including debridement) – bilateral | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0110 | Total excision of nose | Major | |||
| 5.7 | Larynx and trachea | ||||
| E3810 | Injection into larynx | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0712 | Radical trachelectomy including laparoscopic and removal of lymph nodes +/- ureterolysis | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W4920 | Conversion of hemiarthroplasty to total shoulder replacement | Complex | |||
| 2 | Brain, cranium and intracranial organs | ||||
| Excision of lesion of pituitary gland includes packing of the nose and removal of packs where required. These should not be charged separately. Additional charges should not be made for cranioplasty with intracranial procedures. The code for stereotactic ablation of a lesion includes removal/biopsy of the lesion. |
|||||
| 2.2 | Cranium | ||||
| V0382 | Total petrosectomy (for tumour) | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| A6600 | Release of entrapment of deeply placed peripheral nerve | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W3020 | Adjustments to Ilizarov frame/rings | Major | |||
| 16.11 | Foot | ||||
| T6770 | Peroneal sling/groove reconstruction and replacement of dislocated peroneal tendons | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.2 | Stomach | ||||
| G4680 | Endoscopic mucosal resection (upper gastrointestinal tract) (EMR) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0220 | Total oesophagectomy and interposition of intestine | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.7 | Shoulder | ||||
| W8603 | Therapeutic arthroscopy of shoulder (as sole procedure) | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.4 | Consultations and Physicians’ fees | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| V2400 | Posterior decompression with fusion (thoracic region) Including Spinal Cord Monitoring | Complex | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| 16.11 | Foot | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.6 | Mediastinum | ||||
| E6110 | Open excision of mediastinal tumour including congenital cysts/posterior chest wall lesions | Xmajor | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.1 | Spinal column (including intervertebral discs) | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2916 | Mastectomy and immediate reconstruction of breast using extended latissimus dorsi flap | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.6 | Peripheral nerves | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M1350 | Antegrade pyelogram (including bilateral) | Intermediate | |||
| 19 | Haematology (Hospital Use Only) | ||||
| Haematology (Hospital Use Only) | |||||
| 19.1 | Bone Marrow | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W7452 | 2 stage revision anterior cruciate ligament reconstruction - second stage | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2914 | Mastectomy followed by immediate Deep Inferior Epigastric Flap (DIEP) reconstruction - bilateral | Complex | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.4 | Nose and nasal cavity | ||||
| E0220 | Septorhinoplasty (including attention to turbinates) | Major | |||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | ||||
| 1.2 | Simple procedures | ||||
| E2880 | Epley manoeuvre (code for specialist use only) | ||||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q2231 | Laparoscopic oophorectomy and salpingectomy, +/- biopsy eg. omentum, peritoneum, lymph node (as sole procedure) ? unilateral | Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.1 | Connective tissue/tendon muscle | ||||
| T7231 | Open release of constriction of sheath of tendon (e.g. trigger finger) | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.1 | Face and jaws | ||||
| V0721 | Eminectomy of temporomandibular joint - unilateral | Intermediate | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.3 | Burns, scars and contractures | ||||
| S5532 | Dressing of burn of skin or subcutaneous tissue - less than 2% | Minor | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6007 | Planning and preparation for the delivery of rotational total body irradiation (TBI) | ||||
| X6013 | Planning and preparation for the delivery of Proton Beam Therapy (PBT) for ocular tumours | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F5121 | COMBINED OPEN AND ENDOSCOPIC REMOVAL OF SUBMANDIBULAR GLAND STONE | intermediate | |||
| 13 | Pregnancy and confinement | ||||
| 13.0 | Pregnancy and confinement | ||||
| R1240 | Laparoscopic cerclage for cervial incompetence in gravid uterus | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5561 | Endoscopic ablation for an anal fistula with flap | Intermediate | |||
| H5941 | Excision of pilonidal sinus with flap reconstruction | Intermediate | |||
| 11.7 | Other organs (mainly digestive) | ||||
| 11.10 | Peritoneum | ||||
| J9905 | Repeat Cytoreductive Surgery for Pseudomyxoma Peritoneal or Colorectal Peritoneal Carcinomatosis with intraperitoneal chemotherapy | Extra Major | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.2 | Chest wall | ||||
| T0213 | Removal of pectus bar (including bilateral) | Intermediate | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| A5756 | NERVE ROOT BLOCK +/- IMAGE GUIDANCE (INCLUDING BILATERAL) CAUDAL | INTERMEDIATE | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H3385 | Laparoscopic total mesorectal excision (TME) | Complex | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.1 | Kidney/renal pelvic | ||||
| M0550 | Repair of kidney wound | Xmajor | |||
| 12.2 | Ureter | ||||
| M2100 | Other connection of ureter | Major | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.2 | Spinal cord | ||||
| A5580 | CSF infusion studies | Intermediate | |||
| 20 | Radiotherapy | ||||
| It is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery.
Supplementary codes (X9000 - X9049) should be used in addition to delivery codes (X7000 - X7099) to add further information such as the use of image control or motion management techniques and should not be used alone. |
|||||
| 20.0 | Radiotherapy | ||||
| X6575 | Planning, preparation and the delivery of peptide receptor radionuclide therapy for neuroendocrine tumours | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.6 | Rectum/anus | ||||
| H5570 | Injection into complex perianal fistula tract tissue using an Advanced Therapy Medicinal Product (including removal of Setons, curettage and suture of internal openings) | Minor | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
|||||
| 12.3 | Bladder | ||||
| M4400 | Urethral sphincterotomy (including cystoscopy) | Intermediate | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.9 | Thyroid and parathyroid glands | ||||
| B1281 | Percutaneous ultrasound-guided microwave ablation for symptomatic benign thyroid nodules | Minor | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.1 | Oesophagus | ||||
| G0921 | Robotic assisted oesophagocardiomyotomy (Heller's) | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.10 | Knee | ||||
| W8370 | AUTOLOGOUS SCAFFOLD INSERTION FOR REPAIRING SYMPTOMATIC CHONDRAL KNEE DEFECTS (INCLUDING MICROFRACTURE) | Major | |||
| 22 | Gender Affirmation | ||||
|
The procedures listed in this chapter are only available for a limited range of corporate schemes. These are corporate clients who have opted to include this cover. Corporate groups have differing levels of cover so all the published codes may not be available to all of our members and are not available on all plans. |
|||||
| 22.0 | Gender Affirmation | ||||
| GA404 | Hair Transplantation For Gender Affirmation | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 25150 | Trigeminal ganglion injection (local anaesthetic under X-ray control) | Intermediate | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.11 | Foot | ||||
| W0860 | Metatarsophalangeal Cheilectomy - Unilateral, As Sole Procedure | Major | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.2 | Repair | ||||
| S5712 | Debridement of wound (and surgical toilet) - over 25cm² in area | Minor | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.10 | Peritoneum | ||||
| T4680 | Suprapubic drainage of pelvic abscess | Intermediate | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
|||||
| 15.1 | Lesions of skin | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K1600 | Therapeutic transluminal operations on atrial septum of heart | Complex | |||
| L2360 | Repair of interrupted aortic arch | Complex | |||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
|||||
| 3.3 | Paraspinal injections | ||||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
|||||
| 8.8 | Heart – cardiac surgery | ||||
| K2542 | Revision replacement of mitral valve | Complex | |||
| 8.10 | Great Vessels | ||||
| 10 | Endoscopic gastrointestinal procedures | ||||
| The benefit for endoscopic therapeutic procedures includes an amount for diagnostic endoscopy. This
should therefore not be charged for separately. The benefit for gastroscopy and sigmoidoscopy includes an amount for sedation. Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 10.1 | Endoscopic gastrointestinal procedures | ||||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
|||||
| 14.1 | Uterus/adnexa | ||||
| Q0790 | Laparoscopic total hysterectomy, +/- oophorectomy, +/- ureterolysis | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
|||||
| 5.2 | Middle ear and mastoid | ||||
| D1610 | Ossiculoplasty | Xmajor | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
|||||
| 16.3 | Fractures | ||||
| W2300 | Secondary open reduction of fracture of short bone (including intra-articular fracture for delayed/non-union and including bone graft) | Major | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H1200 | Excision of lesion of colon (transabdominal) | Major | |||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
|||||
| 6.6 | Salivary glands | ||||
| F5120 | Open extraction of calculus from submandibular duct | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
|||||
| 11.5 | Large intestine | ||||
| H0210 | Appendicectomy | Major | |||
| 11.7 | Other organs (mainly digestive) | ||||
| J6900 | Open splenectomy | Major | |||
| 17 | Interventional radiology | ||||
| Many therapeutic procedures necessitate a diagnostic procedure. For example, angioplasty cannot be
performed without angiography. We will not reimburse additional charges for these diagnostic procedures unless a separate and distinct procedure took place. We will not normally reimburse standby fees for these procedures. If it is felt to be clinically necessary to have a surgeon on standby, we request you contact the specialist fees team using the telephone numbers at the front of this Schedule. The code and narrative for all these procedures includes imaging guidance by one of the following methods: X-ray, CT/MRI, fluoroscopy or ultrasound. If a vascular procedure is jointly performed by a surgeon and interventional radiologist then the benefit should be split between the two specialists. Separate charges should not be made. |
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| 17.2 | Drainage | ||||
| XR170 | Fluoroscopically guided drainage of fluid collection | Intermediate | |||
| 11 | Abdomen (excluding urinary and reproductive organs) | ||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are encountered, we request that a note of explanation is provided and we will give consideration as to whether we will pay additional benefit. |
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| 11.4 | Small intestine | ||||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| B2912 | Mastectomy and immediate reconstruction of breast using latissimus dorsi | Xmajor | |||
| 15 | Skin and subcutaneous tissue | ||||
| When skin lesions are removed either by excision biopsy or wide excision, the resulting defect can usually
be closed by primary suture. It is our view, therefore, that the primary closure is an intrinsic part of these procedures. When Mohs’ micrographic surgery is performed, the resulting defect is normally of a size and shape that cannot be closed by primary suture. In these cases, a small skin graft or local flap is routinely performed. The benefit for the procedure includes an amount for flap closure. Where the lesion being removed is in a site which causes particular problems, we will allow flexibility, but we ask that sufficient clinical detail is provided with the claim to allow this to be taken into account. Many excisions or excision biopsies are performed under local anaesthesia. This is considered by us to be intrinsic to the procedure and is not eligible for separate benefit. The fee payable for anaesthesia is for care of an unconscious or semiconscious patient during surgery and not for simple administration of an injection. The codes for removal of malignant lesions should only be used where a malignant lesion is removed with a margin of normal tissue and a histology report confirms a malignancy. |
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| 15.2 | Repair | ||||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
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| 16.6 | Hand | ||||
| W3203 | Early open reduction and internal fixation of scaphoid fracture ie within 6 weeks of fracture | Major | |||
| 16.9 | Hip, leg and pelvis | ||||
| W3712 | Primary total hip replacement with or without cement | Xmajor | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
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| 14.1 | Uterus/adnexa | ||||
| 6 | Face, mouth, salivary and thyroid | ||||
| Charges for removal of roots should not be made in conjunction with removal of impacted teeth. When bone grafting is used as part of treatment of a bone cyst, this should not be charged as a separate service. Specifically the code for alveolar bone grafting is not appropriate in these circumstances. Closure of an oro-antral fistula should not be charged in conjunction with removal of impacted teeth/complex buried roots. |
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| 6.2 | Lips | ||||
| F0314 | Primary closure of cleft lip - unilateral including anterior palate | Major | |||
| 7 | Breast | ||||
| 7.3 | Reconstruction | ||||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
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| 12.2 | Ureter | ||||
| 3 | Spine, spinal cord and peripheral nerves | ||||
| There are a large number of codes covering most clinical situations for spinal surgery. The various codes
for spinal decompression, removal of disc fusion and instrumentation should be used singly and not combined except in very unusual circumstances. Spinal fusion includes bone grafting and this should not be charged separately. Spinal decompression includes removal of disc matter and rhizolysis. These should not be charged separately. Spinal surgery is frequently multi-level. Multiple level surgery does not constitute a multiple procedure and will not be reimbursed as such except in the cervical region. Chemonucleolysis includes discography and this should not be charged separately. Codes V4100, V4120 and V4000 are for treatment where the primary pathology is idiopathic adolescent scoliosis. They are not for any other purpose and specifically not for correction of degenerative scoliosis. The code for Posterior Lumbar Interbody Fusion is V3362 and the narrative has been amended to reflect this. |
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| 3.7 | Other nerve blocks | ||||
| 25150 | Trigeminal ganglion injection (local anaesthetic under X-ray control) | Intermediate | |||
| 8 | Thorax and intra-thoracic organs | ||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when this is a routine part of the procedure. Insertion of a chest drain should not be charged for separately with intra-thoracic surgery. |
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| 8.8 | Heart – cardiac surgery | ||||
| K2810 | Percutaneous replacement/implantation of pulmonary valve | Complex | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
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| 5.1 | External ear | ||||
| D0630 | Repair of pinna | Minor | |||
| 5.7 | Larynx and trachea | ||||
| E3520 | Microlaryngoscopy/laryngoscopy +/- biopsy, excision of lesion, polyp or cyst | Intermediate | |||
| 14 | Female reproductive organs | ||||
| The benefit for hysteroscopy includes an amount for D&C and insertion of mirena coil. We will not
reimburse additional charges for this as a separate service. Similarly where a therapeutic hysteroscopy is performed, we will not reimburse an additional charge for a diagnostic hysteroscopy. The benefit for hysterectomy for ovarian malignancy includes an amount for removal of omentum and this should not be listed as extra. Cystoscopy should not be charged as an additional procedure with suspension/uro-gynaecological procedures. We consider insertion of suprapubic catheter to be an intrinsic part of procedures such as a suprapubic sling or retropubic suspension of bladder neck and will not reimburse these as an additional procedure. The benefit for colposcopy includes an amount for punch biopsy. The benefit for therapeutic laparoscopy includes an amount for diagnostic laparoscopy. The code for insertion of prosthesis into the ureter is designed for use by urologists inserting a stent and not for the circumstances where the ureter is being identified during hysterectomy. We recognise that this does involve some additional work and consider that a small uplift would be reasonable. The code for division of adhesions is no longer in our Schedule. Adhesions are a part of a large number of gynaecological pathologies and the benefit for treatment includes an amount for division of adhesions. We do however accept that there are some cases where numerous dense adhesions add considerably to the complexity of a procedure and in such cases suggest an enhanced fee is submitted together with a note of explanation. Postoperative analgesia is part of all surgery. We will not reimburse additional charges by surgeons or anaesthetists for wound infiltration with local anaesthetic. |
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| 14.1 | Uterus/adnexa | ||||
| Q1700 | Therapeutic hysteroscopic operations on uterus (including endometrial ablation excluding microwave or radiofrequency ablation) +/- Mirena coil insertion | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
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| 16.9 | Hip, leg and pelvis | ||||
| W3943 | Removal of total hip replacement and complete clearance of cement | Complex | |||
| 16.11 | Foot | ||||
| T6720 | Percutaneous Lengthening Of Achilles Tendon | Intermediate | |||
| 12 | Urinary system and male reproductive organs | ||||
| We assume that the following (when required) are an intrinsic part of all endoscopic therapeutic
procedures of the urethra, prostate, bladder, ureters and kidney. This includes not only procedures such as resection of bladder tumours and TURP but also insertion and removal of JJ stents, retrograde pyelography etc. M4510 Diagnostic endoscopic examination of bladder (including any biopsy) M7700 Diagnostic endoscopic examination of urethra (as sole procedure) M3000 Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) The following procedures are only eligible for benefit where the primary pathology being treated is a urethral stricture or otherwise in exceptional circumstances. Where the procedure represents gaining access for a cystoscope or other instrument, additional charges should not be made. M7920 Dilatation of urethra (including cystoscopy) M7940 Internal urethrotomy (including cystoscopy) M5820 Dilatation of outlet of female bladder (with cystoscopy) Generally we consider that the various procedures for extraction of calculi include cystoscopy, diagnostic ureteroscopy, retrograde pyelography and insertion of stent where required. We will consider making additional benefit available for difficult procedures on a case by case basis. This does not apply to insertion or removal of stent when performed at a different time from the main procedure. Charges should not be made for anaesthesia with flexible cystoscopy. |
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| 12.1 | Kidney/renal pelvic | ||||
| M0280 | Laparoscopic nephrectomy | Major | |||
| 16 | Bones, joints and connective tissue/tendon muscle | ||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, knee, shoulder and wrist Small joints – all other joints of the hand and foot Child Aged 0-15 Adult Aged 16 and over |
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| 16.9 | Hip, leg and pelvis | ||||
| W1912 | Pinning of head of femur – open or percutaneous (eg slipped femoral epiphysis, undisplaced neck fracture) | Major | |||
| 5 | Ear, nose and throat | ||||
| Septorhinoplasty is only eligible under certain limited circumstances for restoration of normal appearance
immediately after trauma/tumour. The presence of nasal obstruction does not make a septorhinoplasty eligible for benefit. We request that all such procedures are preauthorised to avoid disappointment to policyholders. Uvulopalatoplasty is not included in our schedule and is not eligible under any circumstances for treatment of sleep apnoea. FESS includes removal of nasal polyps, antrostomy and turbinate reduction and these should not be charged as extra. Codes designed for use in theatre should not be used in the out-patient setting, for example nasal cautery or removal of foreign body from nose. Packing of the nose should not be charged as extra with nasal surgery. The code for Epley manoeuvre is soley for use by specialists and practitioners. Where a member has an appointment specifically to undertake the Epley manoeuvre we do not expect to receive a consultation charge. We do not expect to receive any charges from hospitals or facilities for this service unless they are billing on behalf of the service provider. |
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| 5.6 | Throat | ||||
| F3440 | Tonsillectomy - adult, age 13 + (and bilateral) | Intermediate | |||