Governing Rules:

• 4.4.8 CLAIMS REQUIRING REFERRING PRACTITIONER NUMBER

  When a claim is submitted for the following HSCs, the referring practitioner field must be completed with a valid referring practitioner number.

  HSCs in the following list marked with an asterisk(*) cannot be self-referred. Self-referred means the physician is providing the diagnostic service and treating the patient.

  HSCs in Section E (Lab and Pathology) and X (Diagnostic Radiology) require a valid referring practitioner number with the following exceptions: HSC X27D does not require a referral and HSC X27F may be self-referred. HSC 03.03D requires a valid referring physician, chiropractor, midwife, podiatrist, dentist, optometrist, physical therapist or nurse practitioner number when it is a visit to a referred patient.

  01.01A	01.01B	01.03	01.04A	01.05A	01.09
  01.12A	01.12B	01.14	01.16A	01.16B	01.16C
  01.22	01.22A	01.22B	01.22C	01.24A	01.24B
  01.24BA	01.24BB	01.32	01.34	02.82A	02.84A
  02.84B

  03.01O*	03.01LJ* 03.01LK* 03.01LL* 03.03D*	03.03F*
  03.03FA*	03.03FT* 03.03FV* 03.03FZ* 03.04Q*	03.05B*
  03.07A*	03.07AZ* 03.07B*	03.07C*	03.08A*	03.08AZ*
  03.08B*	03.08BZ* 03.08C*	03.08CV* 03.08F*	03.08H*
  03.08K*	03.08L*	03.08M*

  03.09A*	03.09B*	03.12A	03.16A	03.16B	03.16C
  03.16D	03.19C	03.19D	03.21A	03.22A	03.22B
  03.22C	03.26	03.29A	03.37A	03.37B	03.38A
  03.38B	03.38C	03.38D	03.38E	03.38F	03.38G
  03.38H	03.38K	03.38M	03.38N	03.38P	03.38R
  03.38S	03.38T	03.38X	03.41A	03.41B	03.41C
  03.41D	03.44A	03.45A	03.45B	03.52A	03.52B
  03.52C	03.52D	03.55A	03.55B	03.56A	03.56B

  07.09A	07.09B	08.19A*	08.19AZ* 08.19B*	08.19C*
  08.19AA*	08.19BB* 08.19CC* 08.19CX*	09.01A	09.01B
  09.01C	09.01E	09.02B	09.02E	09.05A	09.05B
  09.06A	09.07C	09.11A	09.11B	09.11C	09.12A
  09.12B	09.13C	09.13D	09.13E	09.13F	09.13G
  09.13H	09.23A	09.23B	09.24B	09.26A	09.26D
  09.41A	09.41B	09.43A	09.43B	09.43C	09.43D
  09.43E	09.46A	09.49A

  10.04	10.08A	10.33B	13.99CC 13.99GA*	14.49A
  14.82	14.85B	14.88A	14.88B	15.94A	16.83A
  16.83B	16.83C	16.89A	16.92B	17.81B	19.81

  22.81	24.89A	24.89B	28.8 A	28.81A	29.0 A
  30.81A	33.22B	37.81	37.82A	37.82B	38.89A
  38.89B	39.21A	39.62A	39.83A

  40.92A	41.29A	41.29B	42.09B	43.81	43.82
  44.3 B	45.81A	45.83	45.84B	45.86A	46.5 A
  46.81A	46.82	46.84A	46.88A	48.92A	48.98A
  48.98B	49.93A	49.95A	49.96A	49.96B	49.98B
  49.98C	49.98D

  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	50.95A	50.95B	50.98A
  52.1 A	52.11A	52.12	52.13	52.85A	53.81A
  53.81B	53.83A	54.89A	54.89B	54.89D	54.89E
  54.89F	57.92A

  60.82C	60.89A	62.12A	62.12B	62.81A	63.86A
  63.96B	64.95A	64.97A	66.19A	66.3 C	66.83
  66.89A	66.89B	66.89C	67.81	67.86	67.87A
  67.89A	68.95	69.83A	69.83B	72.91	72.92A
  74.82A	75.83A	76.89A	78.7 A	79.29E

  80.81	80.83B	80.85A	80.85B	82.12A	82.81A
  82.91A	83.7 A	87.53A	87.53B	87.54A	87.55A
  89.59A	89.59B	89.59G	89.98A	92.70	92.71
  92.72	92.74	92.75	92.76	92.78A	92.78B
  92.78C	92.8 A	92.8 B	95.81A	97.11A	97.11B
  97.81	97.82A	97.83A	97.89A	97.89B	98.12A
  98.12B	98.8 A	98.81A	98.81B	98.89A	98.89B
  98.89C	98.89D	98.89E	98.89F	98.89G	98.89H

  F7

• 6.6.2

  If a procedure designated "+" is performed in a physician's office, both the procedural benefit and the appropriate office visit benefit for that day may be claimed, but if a consultation benefit pursuant to GR 6.6.4 has been claimed, a visit benefit will not be payable for the day on which the procedure is performed.

• 6.6.3

  If a procedure designated "+" is performed in a place other than a physician's office, either a procedural benefit or a visit benefit, but not both, may be claimed for that day.

• 6.6.4

  If a procedure designated "+" and a consultation are provided on the same day, both the procedural benefit and the appropriate consultation benefit are payable.

• 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

• 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.