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
- 97
  OPERATIONS ON THE BREAST
  - 97.1
    Excision or destruction of lesion or tissue of breast
  - 97.2
    Other excision or destruction of breast tissue
  - 97.3
    Reduction mammoplasty
  - 97.4
    Augmentation mammoplasty
  - 97.5
    Mastopexy (post mastectomy)
  - 97.7
    Other repair and plastic operations on breast
  - 97.8
    Invasive diagnostic procedures on breast
  - 97.9
    Other operations on the breast
XVII
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 97.96

Removal of tissue expander for breast reconstruction

NOTE:

When removal is the only procedure performed and not part of another procedure.
Bilateral procedures may be claimed using 2 calls.

Category:	1 Major Procedure (pre-operative period: 0 days, post-operative period: 14 days)
Base rate:	$141.17

AMA billing tips:

Tissue expanders either removal or insertion within the inclusive care period may not be claimed.
Tissue expander removal or insertion outside of the inclusive care period may be claimed as a visit.
Inclusive care period refers to the number of days before and after a procedure whereby all visit services (except consultations) are considered to be part of the surgical benefit.

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%
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
UGA	UGA		Yes	Replace Base	$134.85
CALL	NBRSER	1		For Each Call Pay Base At	100%
CALL	NBRSER	2 - 2		For Each Call Pay Base At	75%
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

Governing Rules:

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

6.8.4

Where a procedure is performed under general anesthesia, the following applies:

If the procedure is the only procedure performed at that time, a benefit of $134.85 may be claimed.
If another procedure is also performed at the same encounter and the listed benefit payable in respect of it under the Schedule is greater than $134.85 the physician is entitled to receive that listed benefit plus a percentage of the listed benefit for the lesser procedure(s) calculated in accordance with this Schedule. The $134.85 minimum benefit does not apply to the lesser procedures.
If multiple procedures are performed at the same encounter and the listed benefit payable in respect of each of them under the Schedule is less than $134.85, the physician is entitled to receive a benefit of $134.85 in respect of the greater procedure plus a benefit in respect of each of the lesser procedures that is a percentage of the listed benefit and calculated in accordance with this schedule. The $134.85 minimum benefit does not apply to the lesser procedures.
If multiple procedures are performed at the same encounter and only one of them appears under GR 6.8.4 (e), the physician is entitled to receive a benefit of $134.85 in respect of that procedure plus a benefit in respect of the other procedures that is a percentage of the listed benefit and calculated in accordance with this schedule.

GR 6.8.4 applies to the following HSCs:

01.01A	01.01B	01.03	01.09	01.24A	01.24B
01.24BA	01.24BB	02.84B	03.22A	03.22B	03.25
07.29A	07.57A

10.23	10.25	11.71A	11.81A	12.01	12.21
12.24	12.31	13.59L	13.59N	13.59O	13.99BB
14.09A	17.39E	17.81A	19.81

21.41	21.42	21.69A	21.69C	22.13B	22.13C
22.5 A	22.81	24.22A	24.5	25.1 A	26.91A
28.8 A

30.19A	30.19B	30.9 A	32.01A	32.1	32.21A
32.23A	32.39A	33.22A	33.22B	33.51A	33.51B
33.61A	34.0 A	34.1 A	34.89A	35.0 A	37.81
37.82A	38.0 A	38.89A	39.21A	39.62A	39.83A

40.5	40.92A	43.95A	45.81A	45.83	45.84A
46.04B	46.09B	46.09C	46.84A	49.0	49.82B
49.83A

50.4 A	50.94D	50.94E	50.94F	50.97A	51.43
51.53A	52.1 A	53.81B	53.83A	54.92D	58.99F

60.82C	61.01A	61.29B	61.37A	61.39B	62.81A
64.95A	66.82A	67.81	67.86	67.96A	68.1
68.32B	69.13D	69.29A	69.83A	69.83B

70.1	70.2 A	70.2 B	70.2 H	70.4 F
70.5 A	72.91	74.82A	76.91A	78.7 A	79.29E

80.83B	80.85B	81.8	81.96	82.12A	82.12B
82.12C	82.14D	82.81A	82.91A	83.7 A	87.6
87.72A	87.82	87.89A	87.89B	87.91	87.92
88.92	89.59A

97.81	97.96	98.03A	98.04A	98.12A	98.12B
98.12C	98.12E	98.12G	98.12H	98.12J	98.12K
98.12M	98.12N	98.12Q	98.12R	98.22A	98.49A
98.6 A	98.6 C	98.81A	98.93A	98.93B	98.96A
98.96B	98.96C	98.96D	98.98B

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

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

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

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

Fee Navigator^®

Health Service Codes

Health Service Code 97.96

Removal of tissue expander for breast reconstruction

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

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

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

Fee Navigator®

Health Service Codes

Health Service Code 97.96

Removal of tissue expander for breast reconstruction

NOTE:

AMA billing tips:

Fee modifiers:

Governing Rules:

Fee Navigator^®