Governing Rules:

• 6.1

  If a physician performs a minor procedure and provides a service warranting a claim for an office visit or a home visit on the same day, benefits for both may be claimed only if the services and diagnoses are unrelated.

• 6.2

  If a service is provided in a hospital emergency department, AACC or UCC, only the minor procedure or the visit benefit, whichever is the greater, may be claimed, unless the problems are emergencies and the diagnoses are unrelated.

• 6.7.1

  If a minor procedure (M or M+) is provided with a hospital visit on the same day, only the greater benefit HSC may be claimed.

• 6.9.7

  The section on multiple procedures does not apply where the lesser or secondary procedure is:

  1. a fracture that is otherwise provided for in this Schedule,
  2. a dislocation,
  3. a procedure considered to be part of an inclusive benefit, or
  4. a secondary procedure that is paid in full as an additional item or as an interpretation of a diagnostic test as a listed benefit in the Schedule,
  5. a procedure listed in the following table which may be claimed at 100% when performed as a second or subsequent procedure by any physician, regardless of whether the procedures are performed by one or more physicians and regardless of whether additional incisions are required to perform the procedure. This does not apply to anesthetic services; refer to GR 12.4.9.

     16.09N	16.09O	16.09P	16.3 A	16.3 B	16.43D
     16.43E	16.49B	16.49C	16.49D	16.49E	16.49F
     16.49G	17.08A	17.39C	17.5 D

     52.12

     52.13

     52.42

     65.04C

     65.1 A

     89.09A	89.12A	89.12B	89.19A	89.20A	89.21
     89.22A	89.22B	89.24	89.26A	89.36A	89.36C
     89.37A	89.37B	89.38B	89.38C	89.38D	89.38E
     89.38F	89.38G	89.41A	89.41B	89.42A	89.59F
     89.59G	89.6 A	89.78D	89.78H	89.78I	89.78J
     89.78K	89.78L	89.78M	89.78N	89.78P	89.78Q
     89.78R	89.78S	89.78T	89.78U	89.78V	89.78W
     89.78X	89.78Y	89.85	89.88A

     90.00A	90.01	90.02B	90.02C	90.03A	90.03C
     90.04	90.05A	90.06A	90.06B	90.07A	90.07B
     90.09A	90.09B	90.09C	90.2 A	90.32A	90.32B
     90.34A	90.34B	90.39A	90.5 A	90.5 B	90.6 D

     90.6 E	90.6 F	91.00B	91.00E	91.01E	91.01G
     91.04E	91.05K	91.06C	91.08G	91.08L	91.09A
     91.09B	91.10A	91.14A	91.14B	91.14C	91.15A
     91.15B	91.22A	91.22B	91.30A	91.30B	91.30C
     91.30D	91.30F	91.30G	91.30H	91.30I	91.31B
     91.31C	91.31D	91.31E	91.31F	91.31G	91.31H
     91.31J	91.31K	91.32D	91.33B	91.34A	91.34B
     91.34C

     91.34D	91.34E	91.34F	91.34G	91.34H	91.35A
     91.35B	91.35C	91.35D	91.35G	91.35H	91.35K
     91.35L	91.35M	91.35N	91.36A	91.36B	91.36C
     91.36D	91.36E	91.36G	91.36H	91.36I	91.37A
     91.38A	91.38D	91.38F	91.38H	91.38J	91.38K
     91.44B	91.74B	91.80
     91.80A	91.81	91.82A	91.84A	91.84C	91.84D
     91.85A	91.86	91.87A	91.87B	91.88A	91.88B
     91.88C	91.90A	92.10	92.11	92.14	92.31C
     92.31D	92.31E	92.31F	92.31H	92.31J	92.31K
     92.31L	92.31M	92.31N	92.31P	92.31Q	92.31R
     92.31S

     92.32B	92.32C	92.32D	92.40	92.41	92.44
     92.45	92.46	92.8 A	92.8 B	92.8 C	92.8 D
     93.01A	93.01B	93.02A	93.02B	93.05D	93.05E
     93.06A	93.09B	93.09C	93.09D	93.09E	93.09F
     93.09G	93.09H	93.11A	93.12A	93.12B	93.12C

     93.13A	93.14	93.16A	93.18A	93.18B	93.21
     93.22	93.23	93.24	93.25	93.26A	93.39B
     93.39C	93.41A	93.44A	93.45A	93.45B	93.45C
     93.45D	93.45E	93.45F	93.45G	93.45H	93.45J
     93.45K	93.47A	93.47C	93.49A	93.49B

     93.49C	93.59A	93.6 A	93.6 B	93.69A	93.69B
     93.69C	93.71A	93.71D	93.8 A	93.81A	93.81B
     93.83B	93.83C	93.83D	93.83E	93.83F	93.83G
     93.83H	93.83I	93.83N	93.83O	93.84A	93.85A
     93.87A	93.87E	93.87J	93.87K	93.96B	93.96C
     93.96D

     93.96E	93.96F	93.96G	93.96H	93.96I	93.96J
     93.96K	93.96L	94.01B	94.35A

     95.01B	95.12	95.13A	95.13B	95.14E	95.15A
     95.15B	95.15C	95.15F	95.15G	95.19A	95.29A
     95.32B	95.4 A	95.4 B	95.54A	95.54B	95.54D
     95.54E	95.54F	95.54G	95.65B	95.65C	95.65D
     95.65E	95.65F	95.66B	95.71B	95.75A	95.75B
     95.76A	95.76B	95.76C	95.77A	95.78A	95.78B
     95.78C	95.91C	95.99A	96.05	96.06	96.07
     96.08	96.11A	96.13	96.14	96.15	96.16
     96.17	97.11B	97.22A	97.29A

  6. a procedure listed in the following table that may be claimed at 100% when performed as a second or subsequent procedure through a different incision by any physician, regardless of whether the procedures are performed by one or more physicians. This does not apply to anesthetic services; refer to GR 12.4.

     66.3 B	71.7 A	71.7 B	78.52C	78.99B	79.1 A
     79.3 E	80.19A	80.19B	80.19C	80.19D	80.19E
     80.81	80.83B	81.09	81.29B	81.29C	81.51A
     81.99A	81.99C	82.12A	82.12B	82.12C	82.12D
     82.3 A	82.3 B	82.41A	82.42A	82.51A	82.62A
     82.63	82.64B	82.69B	82.69D	82.69E	82.7 A
     82.81A	82.91A	83.19A	83.4 A	83.4 B	83.5 A
     83.61	83.69B	83.7 A	83.9 A

  7. Procedures in different groups in the following table may be claimed at 100% each when performed at the same operative encounter. For example, procedures listed in group B may be claimed at 100% when performed at the same operative encounter as procedures listed in group A. Two procedures from the same group will continue to be paid at 100% and 75% for second and subsequent procedures. This does not apply to anesthetic services; refer to GR 12.4.

     Group A

     19.3 A	19.7 A	19.7 B	20.12	38.22B	41.42
     43.1 B	43.63A	52.11A	54.09A	54.12

     Group B

     45.1 A

     46.64A

     46.64B

     46.81A

     50.77A

     54.79B

     Group C

     52.89A	53.34	53.53A	54.76A	54.79A	55.2 A
     55.3	56.2	56.39A	56.4 A	56.93A	56.93F
     57.0 A	57.04A	57.12A	57.12B	57.14A	57.42A
     57.42B	57.59A	57.6 A	57.6 B	57.6 D	57.6 E
     57.7	57.82A	57.92A	58.11A	58.39A	58.42A
     58.44A	58.73	58.75A	58.81A	58.81B	58.81C
     59.0 A	60.24C	60.39A	60.4 A	60.52A	60.52B
     60.65	62.12A	62.12C	62.2 B	62.51	63.12A
     63.12B	63.12D	63.14	63.27	63.41	63.69A
     63.89A	64.09A	64.3	64.43A	64.49A	64.7
     65.7 A	65.7 B	65.9 E	66.19B	66.51A	66.52
     66.63	66.89A	67.01A	67.4 D	67.71	69.73B

     Group D

     60.54	60.59A	60.59B	60.66A	60.71B	60.82C
     61.01B	61.03	61.2 A	61.29B	61.36A	61.39B
     61.4 A	61.63A	61.69B	66.3 C	72.52