I
CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES
II
OPERATIONS ON THE NERVOUS SYSTEM
III
OPERATIONS ON THE ENDOCRINE SYSTEM
IV
OPERATIONS ON THE EYES
V
OPERATIONS ON THE EARS
VI
OPERATIONS ON THE NOSE, MOUTH,AND PHARYNX
VII
OPERATIONS ON THE RESPIRATORY SYSTEM
VIII
OPERATIONS ON THE CARDIOVASCULAR SYSTEM
IX
OPERATIONS ON THE HEMIC AND LYMPHATIC SYSTEMS
X
OPERATIONS ON THE DIGESTIVE SYSTEM AND ABDOMINAL REGION
XI
OPERATIONS ON THE URINARY TRACT
XII
OPERATIONS ON THE MALE GENITAL ORGANS
XIII
OPERATIONS ON THE FEMALE GENITAL ORGANS
XIV
OBSTETRIC PROCEDURES
XV
OPERATIONS ON THE MUSCULOSKELETAL SYSTEM
XVI
OPERATIONS ON THE BREAST
XVII
OPERATIONS ON SKIN AND SUBCUTANEOUS TISSUE
- 98
  OPERATIONS ON SKIN AND SUBCUTANEOUS TISSUE
  - 98.0
    Incision of skin and subcutaneous tissue
  - 98.1
    Excision of skin and subcutaneous tissue
  - 98.2
    Suture of skin and subcutaneous tissue
    - 98.22
      Suture of skin and subcutaneous tissue of other sites
      - 98.22A
        Laceration, face, up to 2.5 cms (1 unit) or body, up to 5 cms (1 unit)
        NOTE: See 98.22B for further notes and for lacerations exceeding the lengths listed above.
      - 98.22B
        Laceration, face, over 2.5 cms (1 unit) and/or body, over 5 cms (1 unit)
        For each layer or unit, refer to Price List
        NOTE: The following applies to HSCs 98.22A and 98.22B. 1. Benefit includes primary closure of wound by any method excluding adhesive tape skin closure or simple bandaging, normal wound care follow-up and suture removal. 2. Where the laceration is treated with the use of adhesive tape skin closure or simple bandaging, a visit should be claimed. 3. Where multiple lacerations are repaired, use the combined length. 4. May only be claimed when the laceration is a result of a trauma either minor or major. 5. May not be claimed in addition to an elective procedure.
  - 98.4
    Free skin graft
  - 98.5
    Flap or pedicle graft
    NOTE: 1. Functional areas includes the following anatomical areas: Head, neck, axillae, elbow, wrist, hand, groin, perineum, hip, knee, ankle, foot and includes coverage of exposed vital structures (bone, tendon, major vessel, nerve) 2. Flaps (HSCs 98.53,98.5A,98.51A,98.51B) for functional areas are designated by FNCAR modifier, add 50% to total benefit. 3. Flap size 5-10 cms or double Z-plasty designated by 2ZPL modifier, add 25% to benefit. 4. Flap size greater than 10 cms or triple Z-plasty designated by 3ZPL modifier, add 50% to benefit. 5. Composite tissue resection (includes bone) designated by CMPRSC modifier, add 25% to benefit. 6. Only one modifier (CMPRSC, FNCAR, 2ZPL, 3ZPL) may be claimed per flap.
  - 98.6
    Plastic operations on lip and external mouth
  - 98.7
    Other repair and reconstruction of skin and subcutaneous tissue
  - 98.8
    Invasive diagnostic procedures on skin and subcutaneous tissue
  - 98.9
    Other operations on skin and subcutaneous tissue
XVIII
PROCEDURES NOT ELSEWHERE CLASSIFIED
LABORATORY AND PATHOLOGY
DIAGNOSTIC RADIOLOGY
NOTE: As stated in G.R. 11.1.1, claims for services in the Diagnostic Radiology section will not be payable unless the physician has been approved by the CPSA to provide those services.
THERAPEUTIC RADIOLOGY

Health Service Code 98.22B

Laceration, face, over 2.5 cms (1 unit) and/or body, over 5 cms (1 unit)

For each layer or unit, refer to Price List

NOTE:

The following applies to HSCs 98.22A and 98.22B.

Benefit includes primary closure of wound by any method excluding adhesive tape skin closure or simple bandaging, normal wound care follow-up and suture removal.
Where the laceration is treated with the use of adhesive tape skin closure or simple bandaging, a visit should be claimed.
Where multiple lacerations are repaired, use the combined length.
May only be claimed when the laceration is a result of a trauma either minor or major.
May not be claimed in addition to an elective procedure.

Category:	1 Major Procedure (pre-operative period: 0 days, post-operative period: 14 days)
Base rate:	$61.77

AMA billing tips:

Remember the 3 L's: Length, location, layers.
Length and Location For total lengths that are over any unit by any amount, round up to the next unit. Facial lacerations = 2.5 cm per unit (ears, under jaw bone and hair line forward is considered the face). Body lacerations = 5.0 cm per unit (remainder of body including scalp)
Layers For multiple layered lacerations, measure and count each layer separately
Read more

Fee modifiers:

Type	Code	# of calls	Explicit	Action	Amount
BMI	BMIANE		Yes	Increase By	25%
BMI	BMIANT		Yes	Increase By	25%
BMI	BMIPRO		Yes	Increase By	25%
AGE	L10			Increase Base To	130%
ROLE	ANE		Yes	Replace Base	$112.29
ROLE	ANEST		Yes	Replace Base	$18.70
ANU	ANU	1		For Each Call Pay Base At	100%
ANU	ANU	2 - 150		For Each Call Increase By	$18.70
CALL	F2.5B5	1		For Each Call Pay Base At	100%
CALL	F2.5B5	2 - 12		For Each Call Increase By	$30.91
TRAY	MAJT			Increase By	$38.88
NBTR	NBTR		Yes
SURC	EV		Yes	Increase By	$48.82
SURC	NTAM		Yes	Increase By	$117.12
SURC	NTPM		Yes	Increase By	$117.12
SURC	WK		Yes	Increase By	$48.82
LVP	LVP75		Yes	Reduce Base To	75%

Governing Rules:

6.3
A procedure benefit includes removal of sutures. The physician who placed sutures may not claim for removing them. A second physician who is in the same practice group as the surgeon may not claim for removing the sutures either. However, a second physician may claim a visit for removal of sutures if he is not a member of the same practice group as the practitioner who put the sutures in.
6.8.1
HSCs with a designated category code of 1 and 15 include related post-operative services and those with a designated category code of 3, 4, 6 and 14 include both related pre-operative and post-operative services.
1. a consultation benefit may be claimed up to and including the day of surgery.
2. pre-operative hospital care may be claimed by the physician who performs the surgery if information is submitted to show that conservative treatment was attempted before surgery was performed.
3. benefits may be claimed as applicable for complications occurring during or following post-operative time periods.
4. Deleted
5. HSC 03.04R may be claimed in the pre-operative time frame when all conditions in the notes have been met.
The following chart gives the pre-operative and post-operative periods.
Category Pre-operative Post-operative
1 0 - Days 14 - Days
3 7 - Days 7 - Days
4 7 - Days 14 - Days
6 14 - Days 14 - Days
14 30 - Days 14 - Days
15 0 - Days 7 - Days

13.3

Benefits may not be claimed for procedures that do not routinely require the services of a surgical assistant or a 2nd surgeon for a 2nd surgical team, unless supporting information detailing unusual circumstances satisfactory to the Minister is provided. Such procedures include but are not limited to the following list:

01.01A	01.01B	01.03	01.04A	01.05A	01.09
01.12B	01.14	01.16B	01.16C	01.22	01.22A
01.22B	01.22C	01.24A	01.24B	01.24BA	01.24BB
01.32	01.34	02.84A	02.84B

06.35A	06.35B	06.39A	06.39B	07.09A	07.27A
07.27B	07.29A	07.29B	07.51A	07.51C	07.53A
07.53B	07.53C	07.53D	07.53E	07.54A	07.56A
07.57A	07.57B	09.01A	09.01B	09.01C	09.01F
09.05A	09.06A	09.07C	09.11A	09.12A	09.26A
09.49A

15.93A	15.93B	15.93C	15.94A	15.99A	16.2 B
16.81A	16.83A	16.83B	16.83C	16.89A	16.92A
17.03A	17.08D	17.08E	17.08K	17.1 A	17.39E
17.71A	17.81A	17.89A	18.29A	18.29B	19.81

40.0	40.1 A	40.5	40.92A	41.29A	41.29B
42.09A	42.09B	43.1 B	43.81	43.82	43.95A
43.96A	43.96B	43.96C	43.96D	43.96E	44.01
44.22A	45.81A	45.83	45.84A	45.88A

52.1 A	52.85A	53.42A	53.81A	53.81B	53.83A
54.21B	54.21C	54.21D	54.21E	54.89A	54.89B
54.89D	54.89E	54.89F	54.91A	54.92A	54.92B
54.92C	54.92D	54.92E	55.41A	55.41B	56.34A
56.93B	57.21A	57.92A	58.99B

70.1	70.2 A	70.2 B	70.2 H	70.4 F	70.4 G
70.5 A	70.5 B	71.8	71.95	71.96A	72.1 C
72.91	73.2 A	73.91	74.82A	75.64	75.83A
76.0	76.1 A	76.89A	76.91A	78.7 A	79.22
79.23A	79.29C	79.29E

80.81	80.83B	80.85A	80.85B	81.01D	81.09
81.8	81.91A	81.96	82.12A	82.12B	82.12C
82.81A	82.91A	83.09A	83.2 B	83.7 A	84.21D
85.5 A	87.3	87.53A	87.54A	87.54B	87.55A
87.6	87.99A	87.99AA	88.02A	88.92	89.98A

91.00A	91.01A	91.01B	91.01H	91.01J	91.02A
91.02C	91.02D	91.03A	91.03B	91.04A	91.04B
91.05A	91.06B	91.06D	91.06E	91.07A	91.08B
91.08J	91.12A	91.13A	91.72	91.73A	91.73B
91.77C	91.78B	91.78C

92.70	92.71	92.72	92.74	92.75	92.76
92.78A	92.78B	92.78C	93.91A	93.91B	95.03
95.81A	95.93	95.96A	96.01A	96.01B	96.02A
96.02B	96.11A	97.81	97.83A	97.89A	97.89B
97.96

14.1
A major tray service benefit may be claimed for the following procedures only when they are performed in a location other than a nursing home, general or auxiliary hospital, AACC, UCC or a facility which has a contract with a regional health authority to provide any of these insured services.
01.03 01.04A 01.05A 01.24A 01.24B 01.24BA
01.24BB 01.34 02.84A 02.84B 03.22B 03.25
07.53B 07.53D 07.53E 07.57A
12.31 13.59C 17.08A 17.81A 18.29F 18.29FA
21.42 21.69A 22.13A 22.13B 22.13C 22.5 A
22.51A 22.62A 22.71 22.81 25.1 A 25.29A
25.39D
32.01A 32.81 33.02A 33.22B 34.0 A 34.1 A
34.89A 37.82A 38.89A 39.21A 39.62A 39.83A
39.83A
40.92A 46.91
50.4 A 50.97A 52.1 A 52.11A 52.13 56.93B
60.24C 61.01B 61.03 61.29B 61.37A 61.39B
66.91A
70.1 70.5 A 72.91 75.64 79.23A 79.29E
82.81A 82.91A 83.7 A 87.3 87.55A 89.37A
89.37B 89.41A 89.41B 89.42A
93.39B 93.39C 95.02A 95.09A 95.81A 97.11B
97.83A 97.89B 98.04A 98.6 A 98.6 B 98.12A
98.12B 98.12C 98.12H 98.12J 98.12M 98.12N
98.12Q 98.12R 98.12T 98.14A 98.22A 98.22B
98.71D 98.81A 98.96A 98.96B 98.96C 98.96D
14.3 MULTIPLE TRAY SERVICE
If multiple procedures listed under GRs 14.1 and 14.2 are performed during the same encounter in a location other than a nursing home, general or auxiliary hospital, AACC, UCC or a facility which has a contract with a regional health authority to provide any of these insured services, the following applies:
14.3.1
For the same anatomical area (example - 3 moles removed from the face), only one tray may be claimed except when the condition relates to suspected cancer or infection, in which case, if required, additional tray(s) may be claimed at 50%.
14.3.2
For different anatomical areas, the tray for the initial procedure may be claimed at 100% and if required, the tray for each additional procedure may be claimed at 50%.
14.3.3
Benefits for additional trays may not exceed the benefit listed for one major tray.
18.1
The Body Mass Index (BMI) modifier may be claimed for selected procedures, obstetrical services, anesthesia, second qualified surgeon and surgical assistant services provided in any location when the following criteria are met:
1. An adult patient has a body mass index of 40 or more.
2. A patient under 18 years of age who is above the 97th percentile for BMI on an approved pediatric growth curve.
3. The following HSCs are only eligible for the BMI modifier when the service is provided under general, spinal, epidural anesthetic or regional nerve block performed in an operating room, day surgery or surgical suite: 98.11A, 98.11B, 98.11C, 98.11D, 98.11E, 98.11F, 98.22A, 98.22B.

03.16A	03.21A	03.22A	03.22B	03.22C	03.26
03.29A	03.37A	03.38A	03.38B	03.38C	03.38D
03.38E	03.38F	03.38G	03.38H	03.38K	03.38M
03.38N	03.38P	03.38Q	03.38R	03.38S	03.38T
03.38X	03.41A	03.44A	03.45A	03.45B	03.52A
03.52C	03.55A	03.56A	03.63

10.04	10.08A	10.16A	10.23	10.25	10.33A
10.33B	10.35	10.55A	10.56A	11.02	11.02A
11.81A	12.01	12.03	12.05	12.12A	12.12B
12.13A	12.21	12.23	12.24	12.31	13.4 A
13.42A	13.53A	13.55A	13.57A	13.59A	13.59B
13.59C	13.59D	13.72A	13.99A	13.99AA	13.99B
13.99BB	13.99C	13.99D	14.3 B	14.85B

20.55B	21.31B	21.32B	21.32D	21.41	21.42
21.69A	22.13A	22.13B	22.13C	22.39A	22.5 A
22.5 B	22.62A	22.71	22.81	23.99A	23.99C
23.99D	24.22A	24.5	24.89A	24.89B	24.91
25.1 A	25.29A	25.81A	27.4 A	27.5 A	27.7 A
27.7 C	27.73A	28.1 A	28.4 A	28.5 A	29.91

30.19A	30.19B	30.81A	30.9 A	32.01A	32.1
32.31	32.81	33.01A	33.02A	33.03A	33.21A
33.22A	33.22B	33.4 C	33.51A	33.51B	33.61A
33.76A	33.76B	33.76C	33.76D	33.76E	33.76F
33.76G	34.0 A	34.1 A	34.54A	34.89A	35.0 A
37.81	37.82A	37.82B	38.0 A	38.89A	38.89B
39.21A	39.62A	39.83A

46.04A	46.04B	46.09B	46.09C	46.84A	46.88A
46.91	47.02B	47.03A	48.92A	48.98A	48.98B
49.0	49.61B	49.7 D	49.7 N	49.73A	49.81
49.82A	49.82B	49.83A	49.84	49.85	49.86
49.93A	49.95A	49.96A	49.96B	49.98B	49.98C
49.98D	49.98P	49.98Q	49.98R	49.98S	49.98T
49.98U

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Health Service Codes

Health Service Code 98.22B

Laceration, face, over 2.5 cms (1 unit) and/or body, over 5 cms (1 unit)

For each layer or unit, refer to Price List

NOTE:

AMA billing tips:

Fee modifiers:

Governing Rules:

Category	Pre-operative	Post-operative
1	0 - Days	14 - Days
3	7 - Days	7 - Days
4	7 - Days	14 - Days
6	14 - Days	14 - Days
14	30 - Days	14 - Days
15	0 - Days	7 - Days

50.4 A	50.6 B	50.71C	50.75E	50.79A	50.81A
50.81B	50.81C	50.81D	50.81E	50.82A	50.82B
50.83A	50.84A	50.84B	50.84C	50.87A	50.87B
50.87C	50.88A	50.89A	50.89B	50.89C	50.89D
50.89E	50.91B	50.91D	50.91E	50.93A	50.94D
50.94E	50.94F	50.95A	50.95B	50.96	50.97A
50.98A	50.99A	50.99D	51.52A	51.53B	51.59B
51.65A	51.65B	51.92A	51.92B	51.99A	51.99B

60.82C	60.89A	61.01A	61.03	61.29B	61.37A
61.39B	62.81A	62.82A	63.96B	63.99A	63.99B
63.99C	64.95A	64.97A	66.83	66.89B	66.89C
66.91B	66.91C	66.98A	67.02	67.81	67.83
67.86	67.87A	67.89A	67.93	67.96A	68.0 A
68.95	68.99A	68.99B	69.11	69.13D	69.29A
69.29B	69.29C	69.83A	69.83B	69.94

98.03A	98.03C	98.03E	98.04A	98.04B	98.12A
98.12B	98.12C	98.12G	98.12J	98.12K	98.12L
98.12M	98.12N	98.12Q	98.12R	98.12S	98.12T
98.12U	98.13A	98.22A	98.22B	98.6 A	98.8 A
98.81A	98.81B	98.89A	98.89B	98.89C	98.89D
98.89E	98.89F	98.89G	98.92C	98.93A	98.93B
98.96A	98.96B	98.96C	98.96D	98.98B	98.99AA

93.39B	93.39C	95.02A	95.09A	95.81A	97.11B
97.83A	97.89B	98.04A	98.6 A	98.6 B	98.12A
98.12B	98.12C	98.12H	98.12J	98.12M	98.12N
98.12Q	98.12R	98.12T	98.14A	98.22A	98.22B
98.71D	98.81A	98.96A	98.96B	98.96C	98.96D

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Health Service Codes

Health Service Code 98.22B

Laceration, face, over 2.5 cms (1 unit) and/or body, over 5 cms (1 unit)

For each layer or unit, refer to Price List

NOTE:

AMA billing tips:

Fee modifiers:

Governing Rules:

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