Procedure codes
Index
Copyright
Introduction
10 - Endoscopic gastrointestinal procedures
14 - Female reproductive organs
14.1 - Uterus/adnexa
17 - Interventional radiology
17.6 - Dilatation
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
14 - Female reproductive organs
14.4 - Vagina/perineum
2 - Brain, cranium and intracranial organs
2.3 - Meninges
4 - Eye and orbital contents
4.5 - Conjuctiva
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
2 - Brain, cranium and intracranial organs
2.3 - Meninges
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
14 - Female reproductive organs
14.5 - Vulva/labia
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
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
3.6 - Peripheral nerves
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
6.9 - Thyroid and parathyroid glands
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
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)
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)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
15 - Skin and subcutaneous tissue
15.2 - Repair
17 - Interventional radiology
17.11 - Liver
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
14 - Female reproductive organs
14.2 - Suspension
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
14 - Female reproductive organs
14.3 - Cervix uteri
9 - Vascular system
9.2 - Thoracic vessels
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.3 - Inner ear
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
7 - Breast
7.4 - Other
4 - Eye and orbital contents
4.5 - Conjuctiva
4.6 - Cornea
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
5 - Ear, nose and throat
5.3 - Inner ear
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
17 - Interventional radiology
17.3 - Angioplasty
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
5 - Ear, nose and throat
5.7 - Larynx and trachea
9 - Vascular system
9.5 - Ileo-femoral vessels
5 - Ear, nose and throat
5.3 - Inner ear
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
5 - Ear, nose and throat
5.5 - Nasal sinuses
14 - Female reproductive organs
14.4 - Vagina/perineum
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
9 - Vascular system
9.8 - Lymphatic system
4 - Eye and orbital contents
4.2 - Eyebrow and lid
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
14 - Female reproductive organs
14.4 - Vagina/perineum
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
2 - Brain, cranium and intracranial organs
2.5 - Vessels
14 - Female reproductive organs
14.1 - Uterus/adnexa
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
4 - Eye and orbital contents
4.12 - General
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.9 - Hip, leg and pelvis
16.11 - Foot
2 - Brain, cranium and intracranial organs
2.4 - Nerves
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
17 - Interventional radiology
17.1 - Biopsy
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
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
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
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)
12 - Urinary system and male reproductive organs
12.4 - Urethra
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
11.4 - Small intestine
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
17 - Interventional radiology
17.13 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
17 - Interventional radiology
17.3 - Angioplasty
5 - Ear, nose and throat
5.1 - External ear
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
4 - Eye and orbital contents
4.5 - Conjuctiva
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
5 - Ear, nose and throat
5.1 - External ear
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
6.2 - Lips
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.2 - Spinal cord
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
4 - Eye and orbital contents
4.6 - Cornea
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
8.7 - Video assisted thoracic surgery (VATS)
7 - Breast
7.3 - Reconstruction
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.4 - Urethra
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
17 - Interventional radiology
17.4 - Embolisation
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
4 - Eye and orbital contents
4.2 - Eyebrow and lid
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
9 - Vascular system
9.6 - Non-specific
5 - Ear, nose and throat
5.7 - Larynx and trachea
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.9 - Hip, leg and pelvis
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
15 - Skin and subcutaneous tissue
15.2 - Repair
2 - Brain, cranium and intracranial organs
2.6 - Other
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
4 - Eye and orbital contents
4.2 - Eyebrow and lid
4.5 - Conjuctiva
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.3 - Lacrimal system
12 - Urinary system and male reproductive organs
12.5 - Prostate
2 - Brain, cranium and intracranial organs
2.4 - Nerves
7 - Breast
7.3 - Reconstruction
17 - Interventional radiology
17.3 - Angioplasty
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
9 - Vascular system
9.7 - Varicose veins
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.11 - Foot
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
12.6 - Genitalia
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
17 - Interventional radiology
17.8 - Spine
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
4 - Eye and orbital contents
4.2 - Eyebrow and lid
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.4 - Palate
6.8 - Neck
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.11 - Foot
16.11 - Foot
15 - Skin and subcutaneous tissue
15.2 - Repair
17 - Interventional radiology
17.8 - Spine
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.8 - Elbow
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
8 - Thorax and intra-thoracic organs
8.11 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.7 - Larynx and trachea
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
12 - Urinary system and male reproductive organs
12.2 - Ureter
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
9 - Vascular system
9.5 - Ileo-femoral vessels
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
12.4 - Urethra
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.10 - Great Vessels
5 - Ear, nose and throat
5.1 - External ear
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
14 - Female reproductive organs
14.1 - Uterus/adnexa
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
9 - Vascular system
9.6 - Non-specific
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
4 - Eye and orbital contents
4.3 - Lacrimal system
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)
11.10 - Peritoneum
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.8 - Major vessels
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
6 - Face, mouth, salivary and thyroid
6.4 - Palate
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
4 - Eye and orbital contents
4.11 - Retina
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
4 - Eye and orbital contents
4.3 - Lacrimal system
6 - Face, mouth, salivary and thyroid
6.2 - Lips
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
2 - Brain, cranium and intracranial organs
2.1 - Brain
5 - Ear, nose and throat
5.1 - External ear
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
7 - Breast
7.3 - Reconstruction
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
6.8 - Neck
7 - Breast
7.4 - Other
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
3.5 - Sympathetic nerves
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
9 - Vascular system
9.7 - Varicose veins
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
5 - Ear, nose and throat
5.5 - Nasal sinuses
12 - Urinary system and male reproductive organs
12.3 - Bladder
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
17 - Interventional radiology
17.12 - Urinary
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.2 - Ureter
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
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
5.7 - Larynx and trachea
12 - Urinary system and male reproductive organs
12.5 - Prostate
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
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)
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
14 - Female reproductive organs
14.1 - Uterus/adnexa
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
17 - Interventional radiology
17.4 - Embolisation
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
12 - Urinary system and male reproductive organs
12.3 - Bladder
9 - Vascular system
9.1 - Head and neck
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
9 - Vascular system
9.2 - Thoracic vessels
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
9 - Vascular system
9.5 - Ileo-femoral vessels
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
4 - Eye and orbital contents
4.4 - Muscles
12 - Urinary system and male reproductive organs
12.3 - Bladder
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
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
9.5 - Ileo-femoral vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.7 - Other organs (mainly digestive)
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
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
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
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
12 - Urinary system and male reproductive organs
12.3 - Bladder
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
4 - Eye and orbital contents
4.2 - Eyebrow and lid
4.4 - Muscles
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
12 - Urinary system and male reproductive organs
12.6 - Genitalia
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)
12 - Urinary system and male reproductive organs
12.4 - Urethra
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
5 - Ear, nose and throat
5.3 - Inner ear
4 - Eye and orbital contents
4.6 - Cornea
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
4 - Eye and orbital contents
4.3 - Lacrimal system
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
9 - Vascular system
9.2 - Thoracic vessels
12 - Urinary system and male reproductive organs
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.9 - Hip, leg and pelvis
5 - Ear, nose and throat
5.6 - Throat
9 - Vascular system
9.1 - Head and neck
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
9 - Vascular system
9.6 - Non-specific
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
5 - Ear, nose and throat
5.6 - Throat
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
9 - Vascular system
9.7 - Varicose veins
4 - Eye and orbital contents
4.4 - Muscles
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
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)
4 - Eye and orbital contents
4.2 - Eyebrow and lid
6 - Face, mouth, salivary and thyroid
6.8 - Neck
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
4 - Eye and orbital contents
4.6 - Cornea
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
9 - Vascular system
9.8 - Lymphatic system
17 - Interventional radiology
17.12 - Urinary
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
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
12.4 - Urethra
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
4 - Eye and orbital contents
4.9 - Lens
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
9 - Vascular system
9.6 - Non-specific
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
2 - Brain, cranium and intracranial organs
2.4 - Nerves
15 - Skin and subcutaneous tissue
15.2 - Repair
7 - Breast
7.1 - Excision/biopsy codes
17 - Interventional radiology
17.6 - Dilatation
14 - Female reproductive organs
14.1 - Uterus/adnexa
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
14 - Female reproductive organs
14.1 - Uterus/adnexa
12 - Urinary system and male reproductive organs
12.5 - Prostate
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.1 - External ear
12 - Urinary system and male reproductive organs
12.3 - Bladder
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
12 - Urinary system and male reproductive organs
12.3 - Bladder
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
12 - Urinary system and male reproductive organs
12.5 - Prostate
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
5 - Ear, nose and throat
5.6 - Throat
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
9 - Vascular system
9.5 - Ileo-femoral vessels
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
11.9 - Abdominal wall
14 - Female reproductive organs
14.4 - Vagina/perineum
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
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)
7 - Breast
7.3 - Reconstruction
12 - Urinary system and male reproductive organs
12.3 - Bladder
17 - Interventional radiology
17.13 - Other
12 - Urinary system and male reproductive organs
12.5 - Prostate
12.6 - Genitalia
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
5 - Ear, nose and throat
5.5 - Nasal sinuses
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.6 - Hand
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
12 - Urinary system and male reproductive organs
12.4 - Urethra
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
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
3.7 - Other nerve blocks
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
9 - Vascular system
9.7 - Varicose veins
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
17 - Interventional radiology
17.1 - Biopsy
17.12 - Urinary
2 - Brain, cranium and intracranial organs
2.2 - Cranium
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
4 - Eye and orbital contents
4.3 - Lacrimal system
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.7 - Larynx and trachea
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.11 - Foot
16.12 - External fixation/traction
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
7 - Breast
7.4 - Other
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
3.8 - Other procedures
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.7 - Shoulder
16.12 - External fixation/traction
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
2 - Brain, cranium and intracranial organs
2.1 - Brain
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
12 - Urinary system and male reproductive organs
12.4 - Urethra
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
12 - Urinary system and male reproductive organs
12.6 - Genitalia
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
12 - Urinary system and male reproductive organs
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
9 - Vascular system
9.5 - Ileo-femoral vessels
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
8.11 - Other
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
9 - Vascular system
9.6 - Non-specific
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
4 - Eye and orbital contents
4.1 - Globe and orbit
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
12 - Urinary system and male reproductive organs
12.2 - Ureter
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)
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
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)
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.3 - Bladder
5 - Ear, nose and throat
5.7 - Larynx and trachea
2 - Brain, cranium and intracranial organs
2.6 - Other
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
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
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
5.4 - Nose and nasal cavity
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
12 - Urinary system and male reproductive organs
12.5 - Prostate
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
12 - Urinary system and male reproductive organs
12.3 - Bladder
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
4 - Eye and orbital contents
4.12 - General
12 - Urinary system and male reproductive organs
12.5 - Prostate
9 - Vascular system
9.2 - Thoracic vessels
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.4 - Muscles
17 - Interventional radiology
17.1 - Biopsy
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
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
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
15 - Skin and subcutaneous tissue
15.2 - Repair
6 - Face, mouth, salivary and thyroid
6.4 - Palate
14 - Female reproductive organs
14.1 - Uterus/adnexa
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
9 - Vascular system
9.6 - Non-specific
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
3.5 - Sympathetic nerves
2 - Brain, cranium and intracranial organs
2.2 - Cranium
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.11 - Other
5 - Ear, nose and throat
5.6 - Throat
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.6 - Rectum/anus
9 - Vascular system
9.6 - Non-specific
4 - Eye and orbital contents
4.3 - Lacrimal system
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
16.9 - Hip, leg and pelvis
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
4 - Eye and orbital contents
4.2 - Eyebrow and lid
5 - Ear, nose and throat
5.5 - Nasal sinuses
4 - Eye and orbital contents
4.4 - Muscles
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
14 - Female reproductive organs
14.1 - Uterus/adnexa
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
12 - Urinary system and male reproductive organs
12.3 - Bladder
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.3 - Trachea
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
17 - Interventional radiology
17.3 - Angioplasty
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
2 - Brain, cranium and intracranial organs
2.1 - Brain
12 - Urinary system and male reproductive organs
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
12 - Urinary system and male reproductive organs
12.2 - Ureter
5 - Ear, nose and throat
5.5 - Nasal sinuses
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
8 - Thorax and intra-thoracic organs
8.11 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
9 - Vascular system
9.7 - Varicose veins
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
12 - Urinary system and male reproductive organs
12.4 - Urethra
17 - Interventional radiology
17.8 - Spine
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
4 - Eye and orbital contents
4.10 - Vitreous
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
9 - Vascular system
9.6 - Non-specific
7 - Breast
7.3 - Reconstruction
12 - Urinary system and male reproductive organs
12.3 - Bladder
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
14 - Female reproductive organs
14.1 - Uterus/adnexa
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
14 - Female reproductive organs
14.2 - Suspension
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
2 - Brain, cranium and intracranial organs
2.1 - Brain
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
14 - Female reproductive organs
14.5 - Vulva/labia
4 - Eye and orbital contents
4.10 - Vitreous
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
12 - Urinary system and male reproductive organs
12.3 - Bladder
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
16.8 - Elbow
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
9 - Vascular system
9.6 - Non-specific
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
17 - Interventional radiology
17.13 - Other
7 - Breast
7.3 - Reconstruction
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
8.7 - Video assisted thoracic surgery (VATS)
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.9 - Hip, leg and pelvis
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
7 - Breast
7.4 - Other
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
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
17 - Interventional radiology
17.1 - Biopsy
17.2 - Drainage
5 - Ear, nose and throat
5.1 - External ear
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
9 - Vascular system
9.7 - Varicose veins
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
8.3 - Trachea
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
7 - Breast
7.4 - Other
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
8.11 - Other
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
4 - Eye and orbital contents
4.2 - Eyebrow and lid
17 - Interventional radiology
17.3 - Angioplasty
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
14 - Female reproductive organs
14.1 - Uterus/adnexa
12 - Urinary system and male reproductive organs
12.6 - Genitalia
9 - Vascular system
9.4 - Abdominal vessels
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
14 - Female reproductive organs
14.4 - Vagina/perineum
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)
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
9 - Vascular system
9.5 - Ileo-femoral vessels
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal 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)
16.6 - Hand
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
9 - Vascular system
9.6 - Non-specific
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
9 - Vascular system
9.7 - Varicose veins
6 - Face, mouth, salivary and thyroid
6.4 - Palate
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)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
14 - Female reproductive organs
14.4 - Vagina/perineum
5 - Ear, nose and throat
5.5 - Nasal sinuses
7 - Breast
7.3 - Reconstruction
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
4 - Eye and orbital contents
4.3 - Lacrimal system
5 - Ear, nose and throat
5.5 - Nasal sinuses
12 - Urinary system and male reproductive organs
12.4 - Urethra
5 - Ear, nose and throat
5.5 - Nasal sinuses
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
2 - Brain, cranium and intracranial organs
2.2 - Cranium
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
9 - Vascular system
9.2 - Thoracic vessels
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
9 - Vascular system
9.7 - Varicose veins
2 - Brain, cranium and intracranial organs
2.1 - Brain
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
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
14 - Female reproductive organs
14.4 - Vagina/perineum
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)
4 - Eye and orbital contents
4.7 - Sclera
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
12 - Urinary system and male reproductive organs
12.5 - Prostate
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
12 - Urinary system and male reproductive organs
12.6 - Genitalia
6 - Face, mouth, salivary and thyroid
6.2 - Lips
5 - Ear, nose and throat
5.5 - Nasal sinuses
17 - Interventional radiology
17.11 - Liver
9 - Vascular system
9.4 - Abdominal vessels
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
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
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)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.7 - Shoulder
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
15 - Skin and subcutaneous tissue
15.2 - Repair
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
2 - Brain, cranium and intracranial organs
2.1 - Brain
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
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)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
4 - Eye and orbital contents
4.2 - Eyebrow and lid
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
9 - Vascular system
9.8 - Lymphatic system
7 - Breast
7.3 - Reconstruction
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
8 - Thorax and intra-thoracic organs
8.3 - Trachea
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
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
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.5 - Prostate
18 - Chemotherapy
18.0. - Chemotherapy
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
9 - Vascular system
9.8 - Lymphatic system
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
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)
12 - Urinary system and male reproductive organs
12.3 - Bladder
5 - Ear, nose and throat
5.6 - Throat
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
12 - Urinary system and male reproductive organs
12.2 - Ureter
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.10 - Vitreous
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
4 - Eye and orbital contents
4.4 - Muscles
2 - Brain, cranium and intracranial organs
2.2 - Cranium
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
4 - Eye and orbital contents
4.7 - Sclera
7 - Breast
7.1 - Excision/biopsy codes
9 - Vascular system
9.6 - Non-specific
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
2 - Brain, cranium and intracranial organs
2.3 - Meninges
7 - Breast
7.4 - Other
12 - Urinary system and male reproductive organs
12.4 - Urethra
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
5.7 - Larynx and trachea
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
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
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
3 - Spine, spinal cord and peripheral nerves
3.9 - 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
16.10 - Knee
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
9 - Vascular system
9.8 - Lymphatic system
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.10 - Peritoneum
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
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)
16.6 - Hand
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
12 - Urinary system and male reproductive organs
12.3 - Bladder
9 - Vascular system
9.2 - Thoracic vessels
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
4 - Eye and orbital contents
4.3 - Lacrimal system
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
12 - Urinary system and male reproductive organs
12.4 - Urethra
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
4 - Eye and orbital contents
4.4 - Muscles
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
2 - Brain, cranium and intracranial organs
2.1 - Brain
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.9 - Hip, leg and pelvis
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
9 - Vascular system
9.6 - Non-specific
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
11.4 - Small intestine
11.6 - Rectum/anus
11.7 - Other organs (mainly digestive)
17 - Interventional radiology
17.9 - Thorax
12 - Urinary system and male reproductive organs
12.5 - Prostate
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.4 - Small intestine
5 - Ear, nose and throat
5.1 - External ear
5.4 - Nose and nasal cavity
4 - Eye and orbital contents
4.5 - Conjuctiva
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
9 - Vascular system
9.6 - Non-specific
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
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
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
2 - Brain, cranium and intracranial organs
2.1 - Brain
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
7 - Breast
7.1 - Excision/biopsy codes
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
9 - Vascular system
9.5 - Ileo-femoral vessels
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
4 - Eye and orbital contents
4.5 - Conjuctiva
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
4 - Eye and orbital contents
4.4 - Muscles
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
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)
7 - Breast
7.4 - Other
4 - Eye and orbital contents
4.1 - Globe and orbit
4.2 - Eyebrow and lid
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
6.9 - Thyroid and parathyroid glands
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
9 - Vascular system
9.5 - Ileo-femoral vessels
12 - Urinary system and male reproductive organs
12.3 - Bladder
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
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)
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
12 - Urinary system and male reproductive organs
12.4 - Urethra
12.5 - Prostate
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
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
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
5 - Ear, nose and throat
5.5 - Nasal sinuses
15 - Skin and subcutaneous tissue
15.2 - Repair
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
14 - Female reproductive organs
14.5 - Vulva/labia
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.6 - Throat
17 - Interventional radiology
17.11 - Liver
12 - Urinary system and male reproductive organs
12.5 - Prostate
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
12 - Urinary system and male reproductive organs
12.6 - Genitalia
4 - Eye and orbital contents
4.10 - Vitreous
17 - Interventional radiology
17.4 - Embolisation
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
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
12.5 - Prostate
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.2 - Eyebrow and lid
12 - Urinary system and male reproductive organs
12.4 - Urethra
5 - Ear, nose and throat
5.5 - Nasal sinuses
11 - Abdomen (excluding urinary and reproductive organs)
11.8 - Major vessels
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.9 - Lens
14 - Female reproductive organs
14.3 - Cervix uteri
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
14 - Female reproductive organs
14.5 - Vulva/labia
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
11.9 - Abdominal wall
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.7 - Other organs (mainly digestive)
2 - Brain, cranium and intracranial organs
2.2 - Cranium
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
2 - Brain, cranium and intracranial organs
2.2 - Cranium
17 - Interventional radiology
17.13 - Other
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
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)
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
14 - Female reproductive organs
14.3 - Cervix uteri
14.4 - Vagina/perineum
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
2 - Brain, cranium and intracranial organs
2.5 - Vessels
6 - Face, mouth, salivary and thyroid
6.2 - Lips
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
6 - Face, mouth, salivary and thyroid
6.4 - Palate
14 - Female reproductive organs
14.1 - Uterus/adnexa
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
5 - Ear, nose and throat
5.3 - Inner ear
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)
3.3 - Paraspinal injections
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
2 - Brain, cranium and intracranial organs
2.1 - Brain
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
16.6 - Hand
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.2 - Ureter
17 - Interventional radiology
17.4 - Embolisation
14 - Female reproductive organs
14.3 - Cervix uteri
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.2 - Ureter
4 - Eye and orbital contents
4.9 - Lens
12 - Urinary system and male reproductive organs
12.6 - Genitalia
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
9 - Vascular system
9.6 - Non-specific
2 - Brain, cranium and intracranial organs
2.2 - Cranium
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
16.10 - Knee
4 - Eye and orbital contents
4.2 - Eyebrow and lid
5 - Ear, nose and throat
5.7 - Larynx and trachea
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
17 - Interventional radiology
17.13 - Other
14 - Female reproductive organs
14.1 - Uterus/adnexa
9 - Vascular system
9.8 - Lymphatic system
14 - Female reproductive organs
14.1 - Uterus/adnexa
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.1 - Globe and orbit
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.10 - Knee
12 - Urinary system and male reproductive organs
12.3 - Bladder
18 - Chemotherapy
18.0. - Chemotherapy
4 - Eye and orbital contents
4.11 - Retina
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
9 - Vascular system
9.4 - Abdominal vessels
4 - Eye and orbital contents
4.1 - Globe and orbit
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
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
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
2 - Brain, cranium and intracranial organs
2.5 - Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
2 - Brain, cranium and intracranial organs
2.1 - Brain
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
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
9 - Vascular system
9.8 - Lymphatic system
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.2 - Eyebrow and lid
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
4 - Eye and orbital contents
4.3 - Lacrimal system
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.5 - Prostate
5 - Ear, nose and throat
5.5 - Nasal sinuses
5.6 - Throat
4 - Eye and orbital contents
4.1 - Globe and orbit
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
14 - Female reproductive organs
14.1 - Uterus/adnexa
9 - Vascular system
9.5 - Ileo-femoral vessels
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
8.10 - Great Vessels
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)
17 - Interventional radiology
17.13 - Other
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
12 - Urinary system and male reproductive organs
12.3 - Bladder
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
4 - Eye and orbital contents
4.1 - Globe and orbit
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
4 - Eye and orbital contents
4.11 - Retina
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
9 - Vascular system
9.1 - Head and neck
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
4 - Eye and orbital contents
4.12 - General
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
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
5.2 - Middle ear and mastoid
2 - Brain, cranium and intracranial organs
2.2 - Cranium
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
9 - Vascular system
9.7 - Varicose veins
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
2 - Brain, cranium and intracranial organs
2.1 - Brain
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
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
16.6 - Hand
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
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
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
4 - Eye and orbital contents
4.6 - Cornea
9 - Vascular system
9.2 - Thoracic vessels
12 - Urinary system and male reproductive organs
12.3 - Bladder
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
2 - Brain, cranium and intracranial organs
2.1 - Brain
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.10 - Knee
15 - Skin and subcutaneous tissue
15.2 - Repair
4 - Eye and orbital contents
4.6 - Cornea
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
9 - Vascular system
9.6 - Non-specific
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
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
16.9 - Hip, leg and pelvis
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
4 - Eye and orbital contents
4.5 - Conjuctiva
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
4 - Eye and orbital contents
4.6 - Cornea
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
12 - Urinary system and male reproductive organs
12.6 - Genitalia
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
9 - Vascular system
9.5 - Ileo-femoral vessels
17 - Interventional radiology
17.4 - Embolisation
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)
16.12 - External fixation/traction
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)
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
4 - Eye and orbital contents
4.5 - Conjuctiva
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
2 - Brain, cranium and intracranial organs
2.4 - Nerves
9 - Vascular system
9.5 - Ileo-femoral vessels
9.8 - Lymphatic system
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
12 - Urinary system and male reproductive organs
12.4 - Urethra
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
2 - Brain, cranium and intracranial organs
2.4 - Nerves
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
14 - Female reproductive organs
14.1 - Uterus/adnexa
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
17 - Interventional radiology
17.1 - Biopsy
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
4 - Eye and orbital contents
4.1 - Globe and orbit
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
12.5 - Prostate
5 - Ear, nose and throat
5.1 - External ear
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.8 - Major vessels
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
4 - Eye and orbital contents
4.6 - Cornea
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
7 - Breast
7.4 - Other
17 - Interventional radiology
17.3 - Angioplasty
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.10 - Knee
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
18 - Chemotherapy
18.0. - Chemotherapy
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
4 - Eye and orbital contents
4.1 - Globe and orbit
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
5 - Ear, nose and throat
5.5 - Nasal sinuses
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.11 - Foot
9 - Vascular system
9.4 - Abdominal vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
14 - Female reproductive organs
14.2 - Suspension
6 - Face, mouth, salivary and thyroid
6.2 - Lips
4 - Eye and orbital contents
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
14 - Female reproductive organs
14.2 - Suspension
14.4 - Vagina/perineum
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
15 - Skin and subcutaneous tissue
15.2 - Repair
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
5 - Ear, nose and throat
5.7 - Larynx and trachea
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
12.5 - Prostate
2 - Brain, cranium and intracranial organs
2.1 - Brain
14 - Female reproductive organs
14.2 - Suspension
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
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
8.5 - Bronchi/lungs/pleura
12 - Urinary system and male reproductive organs
12.4 - Urethra
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
4 - Eye and orbital contents
4.9 - Lens
8 - Thorax and intra-thoracic organs
8.3 - Trachea
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
9 - Vascular system
9.7 - Varicose veins
5 - Ear, nose and throat
5.7 - Larynx and trachea
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
7 - Breast
7.4 - Other
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
9 - Vascular system
9.7 - Varicose veins
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
5 - Ear, nose and throat
5.6 - Throat
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
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
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.9 - Abdominal wall
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
4 - Eye and orbital contents
4.3 - Lacrimal system
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
17 - Interventional radiology
17.4 - Embolisation
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
4 - Eye and orbital contents
4.5 - Conjuctiva
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
7 - Breast
7.3 - Reconstruction
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
14 - Female reproductive organs
14.2 - Suspension
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
4 - Eye and orbital contents
4.2 - Eyebrow and lid
2 - Brain, cranium and intracranial organs
2.1 - Brain
2.2 - Cranium
4 - Eye and orbital contents
4.11 - Retina
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
12 - Urinary system and male reproductive organs
12.6 - Genitalia
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
12 - Urinary system and male reproductive organs
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
7 - Breast
7.3 - Reconstruction
9 - Vascular system
9.6 - Non-specific
5 - Ear, nose and throat
5.7 - Larynx and trachea
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
4 - Eye and orbital contents
4.2 - Eyebrow and lid
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
9 - Vascular system
9.8 - Lymphatic system
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.7 - Shoulder
16.7 - Shoulder
6 - Face, mouth, salivary and thyroid
6.4 - Palate
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)
11.9 - Abdominal wall
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.5 - Nasal sinuses
17 - Interventional radiology
17.8 - Spine
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
12 - Urinary system and male reproductive organs
12.4 - Urethra
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
9 - Vascular system
9.1 - Head and neck
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
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
4.1 - Globe and orbit
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
17 - Interventional radiology
17.1 - Biopsy
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
9 - Vascular system
9.8 - Lymphatic system
14 - Female reproductive organs
14.1 - Uterus/adnexa
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
17 - Interventional radiology
17.13 - Other
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)
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
4 - Eye and orbital contents
4.10 - Vitreous
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
17 - Interventional radiology
17.10 - Gastrointestinal
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
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
1.3 - General procedures
1.4 - Consultations and Physicians’ fees
1.5 - Practitioner and Therapist fees
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.10 - Vitreous
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
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.6 - Hand
16.7 - Shoulder
16.8 - Elbow
16.9 - Hip, leg and pelvis
16.10 - Knee
16.11 - Foot
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.10 - Knee
14 - Female reproductive organs
14.1 - Uterus/adnexa
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
3.2 - Spinal cord
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
6 - Face, mouth, salivary and thyroid
6.2 - Lips
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
2 - Brain, cranium and intracranial organs
2.5 - Vessels
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
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)
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
17 - Interventional radiology
17.7 - Head and neck
5 - Ear, nose and throat
5.6 - Throat
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
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)
11.2 - Stomach
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
5 - Ear, nose and throat
5.5 - Nasal sinuses
5.7 - Larynx and trachea
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
16.4 - Nerves
7 - Breast
7.3 - Reconstruction
9 - Vascular system
9.2 - Thoracic vessels
7 - Breast
7.1 - Excision/biopsy codes
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
5.7 - Larynx and trachea
7 - Breast
7.1 - Excision/biopsy codes
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
18 - Chemotherapy
18.0. - Chemotherapy
15 - Skin and subcutaneous tissue
15.2 - Repair
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
14 - Female reproductive organs
14.1 - Uterus/adnexa
4 - Eye and orbital contents
4.10 - Vitreous
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
12 - Urinary system and male reproductive organs
12.3 - Bladder
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
12 - Urinary system and male reproductive organs
12.3 - Bladder
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
4 - Eye and orbital contents
4.2 - Eyebrow and lid
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
8.8 - Heart – cardiac surgery
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
7 - Breast
7.1 - Excision/biopsy codes
9 - Vascular system
9.8 - Lymphatic system
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.5 - Prostate
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
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.5 - Nasal sinuses
5.7 - Larynx and trachea
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.3 - Duodenum
15 - Skin and subcutaneous tissue
15.2 - Repair
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
9 - Vascular system
9.7 - Varicose veins
12 - Urinary system and male reproductive organs
12.4 - Urethra
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
12 - Urinary system and male reproductive organs
12.3 - Bladder
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
9 - Vascular system
9.7 - Varicose veins
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
2 - Brain, cranium and intracranial organs
2.2 - Cranium
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
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)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
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)
11.7 - Other organs (mainly digestive)
7 - Breast
7.3 - Reconstruction
9 - Vascular system
9.6 - Non-specific
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
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
16.11 - Foot
14 - Female reproductive organs
14.4 - Vagina/perineum
14.5 - Vulva/labia
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
17 - Interventional radiology
17.4 - Embolisation
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.11 - Foot
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.3 - Bladder
4 - Eye and orbital contents
4.2 - Eyebrow and lid
7 - Breast
7.3 - Reconstruction
17 - Interventional radiology
17.1 - Biopsy
4 - Eye and orbital contents
4.9 - Lens
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
12 - Urinary system and male reproductive organs
12.6 - Genitalia
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
12 - Urinary system and male reproductive organs
12.4 - Urethra
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)
14 - Female reproductive organs
14.4 - Vagina/perineum
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
9 - Vascular system
9.8 - Lymphatic system
12 - Urinary system and male reproductive organs
12.4 - Urethra
19 - Haematology (Hospital Use Only)
19.1 - Bone Marrow
19.2 - Stem Cell
19.2 - Stem Cell
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
4.7 - Sclera
4.8 - Iris and anterior chamber
2 - Brain, cranium and intracranial organs
2.4 - Nerves
5 - Ear, nose and throat
5.3 - Inner ear
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
9 - Vascular system
9.2 - Thoracic vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
7 - Breast
7.3 - Reconstruction
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
12 - Urinary system and male reproductive organs
12.5 - Prostate
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
17 - Interventional radiology
17.9 - Thorax
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
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)
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
9 - Vascular system
9.5 - Ileo-femoral vessels
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
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
4 - Eye and orbital contents
4.9 - Lens
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
12 - Urinary system and male reproductive organs
12.4 - Urethra
19 - Haematology (Hospital Use Only)
19.2 - Stem Cell
7 - Breast
7.3 - Reconstruction
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
1.2 - Simple procedures
14 - Female reproductive organs
14.5 - Vulva/labia
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
17 - Interventional radiology
17.11 - Liver
18 - Chemotherapy
18.0. - Chemotherapy
7 - Breast
7.3 - Reconstruction
17 - Interventional radiology
17.1 - Biopsy
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
17 - Interventional radiology
17.4 - Embolisation
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
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
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
14 - Female reproductive organs
14.1 - Uterus/adnexa
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
14 - Female reproductive organs
14.1 - Uterus/adnexa
14.2 - Suspension
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
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
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
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
16.10 - Knee
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
14 - Female reproductive organs
14.2 - Suspension
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
9 - Vascular system
9.6 - Non-specific
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
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
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
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
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
9 - Vascular system
9.1 - Head and neck
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
14 - Female reproductive organs
14.1 - Uterus/adnexa
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
17 - Interventional radiology
17.13 - Other
14 - Female reproductive organs
14.1 - Uterus/adnexa
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
17 - Interventional radiology
17.12 - Urinary
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.10 - Knee
16.11 - Foot
17 - Interventional radiology
17.13 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
15 - Skin and subcutaneous tissue
15.2 - Repair
17 - Interventional radiology
17.4 - Embolisation
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
5 - Ear, nose and throat
5.6 - Throat
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)
3.1 - Spinal column (including intervertebral discs)
3.8 - Other procedures
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
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
12 - Urinary system and male reproductive organs
12.4 - Urethra
17 - Interventional radiology
17.13 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
9 - Vascular system
9.8 - Lymphatic system
5 - Ear, nose and throat
5.6 - Throat
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.7 - Other organs (mainly digestive)
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
4 - Eye and orbital contents
4.6 - Cornea
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
4 - Eye and orbital contents
4.11 - Retina
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
12 - Urinary system and male reproductive organs
12.3 - Bladder
17 - Interventional radiology
17.1 - Biopsy
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
14 - Female reproductive organs
14.1 - Uterus/adnexa
4 - Eye and orbital contents
4.2 - Eyebrow and lid
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)
11.6 - Rectum/anus
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
12 - Urinary system and male reproductive organs
12.5 - Prostate
12.6 - Genitalia
20 - Radiotherapy
20.0 - Radiotherapy
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
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)
11.10 - Peritoneum
20 - Radiotherapy
20.0 - Radiotherapy
2 - Brain, cranium and intracranial organs
2.1 - Brain
20 - Radiotherapy
20.0 - Radiotherapy
14 - Female reproductive organs
14.3 - Cervix uteri
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
10 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
11 - Abdomen (excluding urinary and reproductive organs)
11.0 - Abdomen (excluding urinary and reproductive organs)
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
17 - Interventional radiology
17.4 - Embolisation
7 - Breast
7.3 - Reconstruction
14 - Female reproductive organs
14.3 - Cervix uteri
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
12 - Urinary system and male reproductive organs
12.3 - Bladder
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)
11.1 - Oesophagus
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.4 - Muscles
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.6 - Cornea
4.9 - Lens
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
7 - Breast
7.4 - Other
4 - Eye and orbital contents
4.2 - Eyebrow and lid
5 - Ear, nose and throat
5.1 - External ear
14 - Female reproductive organs
14.4 - Vagina/perineum
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
11.9 - Abdominal wall
5 - Ear, nose and throat
5.1 - External ear
2 - Brain, cranium and intracranial organs
2.5 - Vessels
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
4 - Eye and orbital contents
4.4 - Muscles
12 - Urinary system and male reproductive organs
12.6 - Genitalia
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
12 - Urinary system and male reproductive organs
12.5 - Prostate
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
5 - Ear, nose and throat
5.7 - Larynx and trachea
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)
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
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
9 - Vascular system
9.7 - Varicose veins
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
20 - Radiotherapy
20.0 - Radiotherapy
4 - Eye and orbital contents
4.9 - Lens
20 - Radiotherapy
20.0 - Radiotherapy
4 - Eye and orbital contents
4.9 - Lens
18 - Chemotherapy
18.0. - Chemotherapy
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
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
5 - Ear, nose and throat
5.6 - Throat
20 - Radiotherapy
20.0 - Radiotherapy
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
20 - Radiotherapy
20.0 - Radiotherapy
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
2 - Brain, cranium and intracranial organs
2.1 - Brain
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
7 - Breast
7.3 - Reconstruction
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
20 - Radiotherapy
20.0 - Radiotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
4 - Eye and orbital contents
4.11 - Retina
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
20 - Radiotherapy
20.0 - Radiotherapy
7 - Breast
7.3 - Reconstruction
20 - Radiotherapy
20.0 - Radiotherapy
5 - Ear, nose and throat
5.7 - Larynx and trachea
20 - Radiotherapy
20.0 - Radiotherapy
9 - Vascular system
9.6 - Non-specific
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
2 - Brain, cranium and intracranial organs
2.2 - Cranium
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
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)
3.9 - Neurophysiological procedures
4 - Eye and orbital contents
4.4 - Muscles
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.4 - Palate
12 - Urinary system and male reproductive organs
12.5 - Prostate
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
8.10 - Great Vessels
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
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
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
9 - Vascular system
9.8 - Lymphatic system
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
3.3 - Paraspinal injections
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)
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
12 - Urinary system and male reproductive organs
12.3 - Bladder
17 - Interventional radiology
17.3 - Angioplasty
2 - Brain, cranium and intracranial organs
2.2 - Cranium
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
9 - Vascular system
9.3 - Renal vessels
2 - Brain, cranium and intracranial organs
2.2 - Cranium
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
14 - Female reproductive organs
14.2 - Suspension
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
9.7 - Varicose veins
4 - Eye and orbital contents
4.2 - Eyebrow and lid
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.8 - Elbow
4 - Eye and orbital contents
4.2 - Eyebrow and lid
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
7 - Breast
7.1 - Excision/biopsy codes
9 - Vascular system
9.6 - Non-specific
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
14 - Female reproductive organs
14.1 - Uterus/adnexa
12 - Urinary system and male reproductive organs
12.4 - Urethra
14 - Female reproductive organs
14.4 - Vagina/perineum
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
9 - Vascular system
9.7 - Varicose veins
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.10 - Knee
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
11.9 - Abdominal wall
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
4 - Eye and orbital contents
4.1 - Globe and orbit
5 - Ear, nose and throat
5.1 - External ear
12 - Urinary system and male reproductive organs
12.6 - Genitalia
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
6.8 - Neck
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.10 - Great Vessels
2 - Brain, cranium and intracranial organs
2.1 - Brain
4 - Eye and orbital contents
4.1 - Globe and orbit
14 - Female reproductive organs
14.2 - Suspension
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.5 - Nasal sinuses
4 - Eye and orbital contents
4.9 - Lens
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
7 - Breast
7.4 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
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
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
4 - Eye and orbital contents
4.9 - Lens
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
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
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
2 - Brain, cranium and intracranial organs
2.6 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
9 - Vascular system
9.6 - Non-specific
4 - Eye and orbital contents
4.2 - Eyebrow and lid
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
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
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
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
16.7 - Shoulder
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
9 - Vascular system
9.7 - Varicose veins
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.11 - Foot
4 - Eye and orbital contents
4.1 - Globe and orbit
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
15 - Skin and subcutaneous tissue
15.2 - Repair
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
9 - Vascular system
9.6 - Non-specific
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
4 - Eye and orbital contents
4.2 - Eyebrow and lid
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
4 - Eye and orbital contents
4.3 - Lacrimal system
8 - Thorax and intra-thoracic organs
8.11 - Other
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
7 - Breast
7.3 - Reconstruction
17 - Interventional radiology
17.12 - Urinary
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
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
5.6 - Throat
9 - Vascular system
9.2 - Thoracic vessels
5 - Ear, nose and throat
5.1 - External ear
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
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
9 - Vascular system
9.4 - Abdominal vessels
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
5 - Ear, nose and throat
5.3 - Inner ear
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
5 - Ear, nose and throat
5.1 - External ear
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
7 - Breast
7.3 - Reconstruction
7.4 - Other
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
4 - Eye and orbital contents
4.11 - Retina
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
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)
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
9 - Vascular system
9.4 - Abdominal vessels
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
17 - Interventional radiology
17.7 - Head and neck
2 - Brain, cranium and intracranial organs
2.6 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
6 - Face, mouth, salivary and thyroid
6.8 - Neck
9 - Vascular system
9.5 - Ileo-femoral vessels
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
9 - Vascular system
9.4 - Abdominal vessels
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
4 - Eye and orbital contents
4.6 - Cornea
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
17 - Interventional radiology
17.12 - Urinary
5 - Ear, nose and throat
5.1 - External ear
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
14 - Female reproductive organs
14.4 - Vagina/perineum
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)
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
16.12 - External fixation/traction
17 - Interventional radiology
17.3 - Angioplasty
12 - Urinary system and male reproductive organs
12.2 - Ureter
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
5 - Ear, nose and throat
5.3 - Inner ear
5.8 - Fibreoptic endoscopic procedures (GA or LA)
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
4.11 - Retina
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
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)
16.12 - External fixation/traction
4 - Eye and orbital contents
4.1 - Globe and orbit
5 - Ear, nose and throat
5.3 - Inner ear
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.10 - Vitreous
18 - Chemotherapy
18.0. - Chemotherapy
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.2 - Lips
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
9 - Vascular system
9.5 - Ileo-femoral vessels
9.6 - Non-specific
2 - Brain, cranium and intracranial organs
2.6 - Other
15 - Skin and subcutaneous tissue
15.2 - Repair
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
17 - Interventional radiology
17.13 - Other
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
11.10 - Peritoneum
2 - Brain, cranium and intracranial organs
2.1 - Brain
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
11.7 - Other organs (mainly digestive)
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
7 - Breast
7.3 - Reconstruction
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
16.4 - Nerves
17 - Interventional radiology
17.13 - Other
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
12 - Urinary system and male reproductive organs
12.3 - Bladder
12.6 - Genitalia
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
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
4 - Eye and orbital contents
4.3 - Lacrimal system
5 - Ear, nose and throat
5.1 - External ear
7 - Breast
7.1 - Excision/biopsy codes
4 - Eye and orbital contents
4.2 - Eyebrow and lid
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
12 - Urinary system and male reproductive organs
12.2 - Ureter
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
2 - Brain, cranium and intracranial organs
2.4 - Nerves
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
7 - Breast
7.1 - Excision/biopsy codes
4 - Eye and orbital contents
4.9 - Lens
13 - Pregnancy and confinement
13.1 - Pregnancy and confinement
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
17 - Interventional radiology
17.13 - Other
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
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
14.4 - Vagina/perineum
12 - Urinary system and male reproductive organs
12.2 - Ureter
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
3.8 - Other procedures
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
9 - Vascular system
9.1 - Head and neck
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
5 - Ear, nose and throat
5.6 - Throat
9 - Vascular system
9.8 - Lymphatic system
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
9 - Vascular system
9.4 - Abdominal vessels
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
17 - Interventional radiology
17.5 - Thrombolysis
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
9 - Vascular system
9.7 - Varicose veins
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
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
4 - Eye and orbital contents
4.6 - Cornea
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
17 - Interventional radiology
17.4 - Embolisation
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
6 - Face, mouth, salivary and thyroid
6.2 - Lips
12 - Urinary system and male reproductive organs
12.2 - Ureter
14 - Female reproductive organs
14.1 - Uterus/adnexa
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.1 - Investigations
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
16.3 - Fractures
12 - Urinary system and male reproductive organs
12.5 - Prostate
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
11.8 - Major vessels
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
17 - Interventional radiology
17.11 - Liver
12 - Urinary system and male reproductive organs
12.4 - Urethra
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
4 - Eye and orbital contents
4.9 - Lens
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
5 - Ear, nose and throat
5.5 - Nasal sinuses
9 - Vascular system
9.3 - Renal vessels
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
7 - Breast
7.4 - Other
9 - Vascular system
9.8 - Lymphatic system
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
5 - Ear, nose and throat
5.1 - External ear
12 - Urinary system and male reproductive organs
12.5 - Prostate
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
8.6 - Mediastinum
6 - Face, mouth, salivary and thyroid
6.8 - Neck
12 - Urinary system and male reproductive organs
12.6 - Genitalia
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
4 - Eye and orbital contents
4.6 - Cornea
6 - Face, mouth, salivary and thyroid
6.2 - Lips
4 - Eye and orbital contents
4.2 - Eyebrow and lid
4.6 - Cornea
12 - Urinary system and male reproductive organs
12.6 - Genitalia
5 - Ear, nose and throat
5.5 - Nasal sinuses
17 - Interventional radiology
17.8 - Spine
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
12 - Urinary system and male reproductive organs
12.3 - Bladder
14 - Female reproductive organs
14.1 - Uterus/adnexa
9 - Vascular system
9.5 - Ileo-femoral vessels
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
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
9 - Vascular system
9.7 - Varicose veins
17 - Interventional radiology
17.13 - Other
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
17 - Interventional radiology
17.1 - Biopsy
16 - Bones, joints and connective tissue/tendon muscle
16.10 - Knee
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
12 - Urinary system and male reproductive organs
12.5 - Prostate
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
14 - Female reproductive organs
14.3 - Cervix uteri
12 - Urinary system and male reproductive organs
12.3 - Bladder
2 - Brain, cranium and intracranial organs
2.4 - Nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
17 - Interventional radiology
17.3 - Angioplasty
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.11 - Foot
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)
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
17 - Interventional radiology
17.2 - Drainage
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
12 - Urinary system and male reproductive organs
12.6 - Genitalia
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
5 - Ear, nose and throat
5.7 - Larynx and trachea
9 - Vascular system
9.3 - Renal vessels
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
9 - Vascular system
9.6 - Non-specific
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
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
9 - Vascular system
9.2 - Thoracic vessels
8 - Thorax and intra-thoracic organs
8.2 - Chest wall
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
5 - Ear, nose and throat
5.7 - Larynx and trachea
4 - Eye and orbital contents
4.2 - Eyebrow and lid
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
6 - Face, mouth, salivary and thyroid
6.3 - Tongue
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
2 - Brain, cranium and intracranial organs
2.1 - Brain
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
9 - Vascular system
9.6 - Non-specific
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.4 - Nerve roots
7 - Breast
7.3 - Reconstruction
15 - Skin and subcutaneous tissue
15.2 - Repair
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
4 - Eye and orbital contents
4.9 - Lens
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
16.6 - Hand
17 - Interventional radiology
17.13 - Other
4 - Eye and orbital contents
4.11 - Retina
14 - Female reproductive organs
14.1 - Uterus/adnexa
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
14 - Female reproductive organs
14.2 - Suspension
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
4 - Eye and orbital contents
4.2 - Eyebrow and lid
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
14 - Female reproductive organs
14.2 - Suspension
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
6 - Face, mouth, salivary and thyroid
6.4 - Palate
11 - Abdomen (excluding urinary and reproductive organs)
11.3 - Duodenum
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
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
9 - Vascular system
9.7 - Varicose veins
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
7 - Breast
7.3 - Reconstruction
4 - Eye and orbital contents
4.3 - Lacrimal system
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
17 - Interventional radiology
17.4 - Embolisation
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
2 - Brain, cranium and intracranial organs
2.1 - Brain
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
3 - Spine, spinal cord and peripheral nerves
3.3 - Paraspinal injections
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
14 - Female reproductive organs
14.1 - Uterus/adnexa
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
5 - Ear, nose and throat
5.7 - Larynx and trachea
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.2 - Simple procedures
5 - Ear, nose and throat
5.6 - Throat
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
9 - Vascular system
9.6 - Non-specific
4 - Eye and orbital contents
4.2 - Eyebrow and lid
16 - Bones, joints and connective tissue/tendon muscle
16.2 - Bone (non-specific)
14 - Female reproductive organs
14.3 - Cervix uteri
16 - Bones, joints and connective tissue/tendon muscle
16.12 - External fixation/traction
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
12 - Urinary system and male reproductive organs
12.5 - Prostate
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
6 - Face, mouth, salivary and thyroid
6.2 - Lips
4 - Eye and orbital contents
4.1 - Globe and orbit
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
7 - Breast
7.1 - Excision/biopsy codes
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
2 - Brain, cranium and intracranial organs
2.1 - Brain
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
2 - Brain, cranium and intracranial organs
2.4 - Nerves
9 - Vascular system
9.5 - Ileo-femoral vessels
2 - Brain, cranium and intracranial organs
2.4 - Nerves
12 - Urinary system and male reproductive organs
12.2 - Ureter
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)
3.3 - Paraspinal injections
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
2 - Brain, cranium and intracranial organs
2.2 - Cranium
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
7 - Breast
7.3 - Reconstruction
14 - Female reproductive organs
14.5 - Vulva/labia
7 - Breast
7.3 - Reconstruction
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
11.7 - Other organs (mainly digestive)
12 - Urinary system and male reproductive organs
12.2 - Ureter
7 - Breast
7.2 - Mastectomy (excluding implant/reconstruction)
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
7 - Breast
7.3 - Reconstruction
5 - Ear, nose and throat
5.8 - Fibreoptic endoscopic procedures (GA or LA)
14 - Female reproductive organs
14.2 - Suspension
17 - Interventional radiology
17.4 - Embolisation
12 - Urinary system and male reproductive organs
12.2 - Ureter
12.3 - Bladder
15 - Skin and subcutaneous tissue
15.3 - Burns, scars and contractures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
9 - Vascular system
9.7 - Varicose veins
2 - Brain, cranium and intracranial organs
2.3 - Meninges
5 - Ear, nose and throat
5.6 - Throat
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
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
16.9 - Hip, leg and pelvis
3 - Spine, spinal cord and peripheral nerves
3.1 - Spinal column (including intervertebral discs)
17 - Interventional radiology
17.8 - Spine
12 - Urinary system and male reproductive organs
12.3 - Bladder
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
7 - Breast
7.3 - Reconstruction
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
5 - Ear, nose and throat
5.5 - Nasal sinuses
17 - Interventional radiology
17.11 - Liver
5 - Ear, nose and throat
5.1 - External ear
5.8 - Fibreoptic endoscopic procedures (GA or LA)
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)
11.10 - Peritoneum
17 - Interventional radiology
17.1 - Biopsy
17.4 - Embolisation
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
16.11 - Foot
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
2 - Brain, cranium and intracranial organs
2.3 - Meninges
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
12 - Urinary system and male reproductive organs
12.6 - Genitalia
4 - Eye and orbital contents
4.11 - Retina
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
8 - Thorax and intra-thoracic organs
8.3 - Trachea
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
9 - Vascular system
9.8 - Lymphatic system
12 - Urinary system and male reproductive organs
12.3 - Bladder
15 - Skin and subcutaneous tissue
15.4 - Flaps and free skin grafts
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)
16.10 - Knee
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
5 - Ear, nose and throat
5.7 - Larynx and trachea
7 - Breast
7.4 - Other
3 - Spine, spinal cord and peripheral nerves
3.7 - Other nerve blocks
9 - Vascular system
9.1 - Head and neck
9.7 - Varicose veins
8 - Thorax and intra-thoracic organs
8.6 - Mediastinum
11 - Abdomen (excluding urinary and reproductive organs)
11.10 - Peritoneum
9 - Vascular system
9.6 - Non-specific
6 - Face, mouth, salivary and thyroid
6.7 - Teeth
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
5 - Ear, nose and throat
5.5 - Nasal sinuses
14 - Female reproductive organs
14.1 - Uterus/adnexa
4 - Eye and orbital contents
4.3 - Lacrimal system
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
9 - Vascular system
9.8 - Lymphatic system
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
12 - Urinary system and male reproductive organs
12.6 - Genitalia
15 - Skin and subcutaneous tissue
15.2 - Repair
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
2 - Brain, cranium and intracranial organs
2.5 - Vessels
17 - Interventional radiology
17.8 - Spine
8 - Thorax and intra-thoracic organs
8.4 - Fibreoptic endoscopic procedures (GA or LA)
5 - Ear, nose and throat
5.7 - Larynx and trachea
12 - Urinary system and male reproductive organs
12.2 - Ureter
5 - Ear, nose and throat
5.6 - Throat
8 - Thorax and intra-thoracic organs
8.3 - Trachea
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.1 - Connective tissue/tendon muscle
16.7 - Shoulder
5 - Ear, nose and throat
5.1 - External ear
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
9 - Vascular system
9.6 - Non-specific
6 - Face, mouth, salivary and thyroid
6.9 - Thyroid and parathyroid glands
5 - Ear, nose and throat
5.2 - Middle ear and mastoid
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
4 - Eye and orbital contents
4.6 - Cornea
2 - Brain, cranium and intracranial organs
2.1 - Brain
12 - Urinary system and male reproductive organs
12.6 - Genitalia
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
16.9 - Hip, leg and pelvis
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
11.2 - Stomach
14 - Female reproductive organs
14.3 - Cervix uteri
4 - Eye and orbital contents
4.5 - Conjuctiva
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
9 - Vascular system
9.8 - Lymphatic system
5 - Ear, nose and throat
5.3 - Inner ear
6 - Face, mouth, salivary and thyroid
6.5 - Mouth cavity
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
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
15 - Skin and subcutaneous tissue
15.2 - Repair
12 - Urinary system and male reproductive organs
12.3 - Bladder
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
16 - Bones, joints and connective tissue/tendon muscle
16.5 - Joints, including replacement/reconstruction (not listed elsewhere)
5 - Ear, nose and throat
5.5 - Nasal sinuses
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
8 - Thorax and intra-thoracic organs
8.1 - Oesophagus
5 - Ear, nose and throat
5.7 - Larynx and trachea
16 - Bones, joints and connective tissue/tendon muscle
16.3 - Fractures
8 - Thorax and intra-thoracic organs
8.9 - Heart – cardiology
16 - Bones, joints and connective tissue/tendon muscle
16.11 - Foot
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - 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
16.11 - Foot
12 - Urinary system and male reproductive organs
12.3 - Bladder
7 - Breast
7.1 - Excision/biopsy codes
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
14 - Female reproductive organs
14.1 - Uterus/adnexa
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
17 - Interventional radiology
17.2 - Drainage
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
7 - Breast
7.1 - Excision/biopsy codes
9 - Vascular system
9.6 - Non-specific
8 - Thorax and intra-thoracic organs
8.5 - Bronchi/lungs/pleura
12 - Urinary system and male reproductive organs
12.6 - Genitalia
4 - Eye and orbital contents
4.5 - Conjuctiva
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
9 - Vascular system
9.3 - Renal vessels
3 - Spine, spinal cord and peripheral nerves
3.5 - Sympathetic nerves
6 - Face, mouth, salivary and thyroid
6.1 - Face and jaws
5 - Ear, nose and throat
5.7 - Larynx and trachea
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
4 - Eye and orbital contents
4.9 - Lens
14 - Female reproductive organs
14.3 - Cervix uteri
9 - Vascular system
9.8 - Lymphatic system
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
5 - Ear, nose and throat
5.7 - Larynx and trachea
4 - Eye and orbital contents
4.7 - Sclera
5 - Ear, nose and throat
5.7 - Larynx and trachea
11 - Abdomen (excluding urinary and reproductive organs)
11.9 - Abdominal wall
2 - Brain, cranium and intracranial organs
2.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
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
4 - Eye and orbital contents
4.4 - Muscles
8 - Thorax and intra-thoracic organs
8.7 - Video assisted thoracic surgery (VATS)
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
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
4 - Eye and orbital contents
4.1 - Globe and orbit
4.8 - Iris and anterior chamber
12 - Urinary system and male reproductive organs
12.6 - Genitalia
3 - Spine, spinal cord and peripheral nerves
3.8 - Other procedures
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
16.11 - Foot
5 - Ear, nose and throat
5.5 - Nasal sinuses
3 - Spine, spinal cord and peripheral nerves
3.6 - Peripheral nerves
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)
5 - Ear, nose and throat
5.3 - Inner ear
16 - Bones, joints and connective tissue/tendon muscle
16.9 - Hip, leg and pelvis
12 - Urinary system and male reproductive organs
12.3 - Bladder
3 - Spine, spinal cord and peripheral nerves
3.2 - Spinal cord
15 - Skin and subcutaneous tissue
15.1 - Lesions of skin
12 - Urinary system and male reproductive organs
12.3 - Bladder
10 - Endoscopic gastrointestinal procedures
10.1 - Endoscopic gastrointestinal procedures
12 - Urinary system and male reproductive organs
12.1 - Kidney/renal pelvic
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
3 - Spine, spinal cord and peripheral nerves
3.9 - Neurophysiological procedures
5 - Ear, nose and throat
5.5 - Nasal sinuses
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
16.9 - Hip, leg and pelvis
1 - Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures
1.3 - General procedures
11 - Abdomen (excluding urinary and reproductive organs)
11.1 - Oesophagus
4 - Eye and orbital contents
4.9 - Lens
2 - Brain, cranium and intracranial organs
2.1 - Brain
4 - Eye and orbital contents
4.6 - Cornea
15 - Skin and subcutaneous tissue
15.2 - Repair
6 - Face, mouth, salivary and thyroid
6.4 - Palate
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
16.7 - Shoulder
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)
14 - Female reproductive organs
14.4 - Vagina/perineum
5 - Ear, nose and throat
5.1 - External ear
14 - Female reproductive organs
14.4 - Vagina/perineum
5 - Ear, nose and throat
5.4 - Nose and nasal cavity
8 - Thorax and intra-thoracic organs
8.10 - Great Vessels
16 - Bones, joints and connective tissue/tendon muscle
16.6 - Hand
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)
2 - Brain, cranium and intracranial organs
2.3 - Meninges
5 - Ear, nose and throat
5.5 - Nasal sinuses
16 - Bones, joints and connective tissue/tendon muscle
16.7 - Shoulder
16.9 - Hip, leg and pelvis
6 - Face, mouth, salivary and thyroid
6.6 - Salivary glands
4 - Eye and orbital contents
4.1 - Globe and orbit
4.6 - Cornea
11 - Abdomen (excluding urinary and reproductive organs)
11.5 - Large intestine
5 - Ear, nose and throat
5.6 - Throat
11 - Abdomen (excluding urinary and reproductive organs)
11.2 - Stomach
8 - Thorax and intra-thoracic organs
8.8 - Heart – cardiac surgery
8.9 - Heart – cardiology
14 - Female reproductive organs
14.4 - Vagina/perineum
11 - Abdomen (excluding urinary and reproductive organs)
11.7 - Other organs (mainly digestive)
7 - Breast
7.3 - Reconstruction
16 - Bones, joints and connective tissue/tendon muscle
16.4 - Nerves
4 - Eye and orbital contents
4.6 - Cornea
17 - Interventional radiology
17.3 - Angioplasty
11 - Abdomen (excluding urinary and reproductive organs)
11.4 - Small intestine
4 - Eye and orbital contents
4.8 - Iris and anterior chamber
5 - Ear, nose and throat
5.5 - Nasal sinuses
11 - Abdomen (excluding urinary and reproductive organs)
11.6 - Rectum/anus
17 - Interventional radiology
17.13 - Other
14 - Female reproductive organs
14.5 - Vulva/labia
5 - Ear, nose and throat
5.5 - Nasal sinuses
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.
- 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 as a meeting between patient and provider to:
- evaluate the nature and progress of an active condition
- establish a diagnosis, prognosis and treatment plan.
Consultations should be face-to-face, unless you have an agreement with us for remote or telephone consultations. We allow Mental Health Practitioners to perform remote consultations if this is within their scope of practice. 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, which includes room and other charges, regardless of time taken or complexity. 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 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.
Please see Section 2.3 of these Principles for guidance on submitting an exception to this principle.
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, in line with national guidelines and evidence-based practice and where the tests are required to direct and manage a patient's treatment plan.
For example, we would expect to see patients managed for sepsis according to the NICE sepsis quality standards https://www.nice.org.uk/guidance/qs161/chapter/Quality-statement-2-Senior-review-and-antibiotic-treatment
We would therefore expect, for example, to see a hospital charge for a lactate blood test, but not for a D-dimer blood test (unless this was also indicated by other relevant clinical symptoms).
We will not generally pay you separately for diagnostic tests, pathology or diagnostic radiology 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 with the facility.
You may bill for therapeutic interventional radiology following our Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/
For diagnostic tests you perform in your private consulting rooms you should submit invoices using CCSD coding and narratives published on the CCSD website https://www.ccsd.org.uk/
We will accept invoices for specimens taken in your private consulting rooms from any recognised pathology facility which has an agreement with us.
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.
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.
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
- 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.
- 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.
- more than one specialism is clinically necessary (a gynaecological surgeon and a colorectal surgeon, for example), or
- clinical guidance from a UK professional body (or another medical entity we recognise) indicates that two or more specialists from the same specialism need to be present during the surgery.
- details of each specialist
- an explanation of why each specialist needs to be in surgery
- the anticipated procedure length and an indication of time in theatre for each specialist
- an explanation of what each specialist will do
- an indication of fees for each specialist and any supporting clinical guidance.
- your role in the procedure
- the time spent in theatre and
- the complexities faced.
Where you anticipate a procedure will be more complex than expected, for a specific clinical reason, we will estimate the fee. We will need:
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:
Multiple Specialist Requests
We will consider requests for two or more surgeons during a patient's operation, either because:
You must agree these requests before going ahead with the procedure. Please send us the following information to support this request:
When agreeing treatment we will provide an estimate of fees paid for each specialist. If, after treatment, you would like us to adjust our estimate, please send us your operation notes and anaesthetic charts, so we can understand:
We will then confirm the fee we will pay you for the treatment.
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
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@axa-ppp.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.
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.
| 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. |
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| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0950 | Plastic reconstruction of uterus | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.6 | Dilatation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR565 | Percutaneous dilatation of biliary stricture under imaging control | Xmajor | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4542 | Open reduction, internal fixation and revision of femoral component for peri-prosthetic fracture | Complex | £750.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5400 | Anorectal stretch | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2450 | Sacrospinous fixation | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.3 | Meninges | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A3900 | Repair of dura | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3910 | Excision/biopsy of conjunctival lesion | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0310 | Resection of liver tumour(s) | Complex | £1,600.00 | £649.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.3 | Meninges | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A3810 | Excision of lesion of meninges of brain | Complex | £1,900.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22000 | Routine electroencephalography (EEG) in adult or child aged over 5 (Including reporting) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P0580 | Radical vulvectomy (including block dissection of inguinal gland) | Complex | £1,200.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0720 | Disarticulation of shoulder | Xmajor | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2430 | Transabdominal anti-reflux operations | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6080 | Neurectomy (major nerve) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1646 | Open reduction/internal fixation of sacro-iliac joint | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0464 | Complex procedure to mid foot and hind foot with autogenous graft (including osteotomy, fusion +/? tendon transfers, fixation) | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5640 | Excision of anal fissure | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25022 | Stellate ganglion block (local anaesthetic) +/- Image Guidance | £150.00 | £142.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5610 | Pancreatoduodenectomy and excision of surrounding tissue (Whipple's procedure) | Complex | £1,900.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3181 | Prosthetic intervertebral disc replacement in the thoracic spine including spinal cord monitoring | Complex | £1,300.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5710 | Excision arthroplasty of first metatarso-phalangeal joint, (e.g. Keller, Bonney-Kessel procedures) including cheilectomy | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J2800 | Excision of lesion of bile duct | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0960 | Excision of benign tumour of bone with bone grafting | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.11 | Liver | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR580 | Percutaneous cholecystostomy | Major | £550.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6302 | Graft to major nerve | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5300 | Vaginal operations to support outlet of female bladder (including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1000 | Excision of sigmoid colon | Xmajor | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3090 | Core decompression of knee | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1100 | Closure of defect of interventricular septum | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8580 | Multiple arthroscopic operation on knee (including meniscectomy, chondroplasty, drilling or microfracture) ? bilateral | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1010 | Dilation of cervix uteri and curettage of retained products of conception following miscarriage | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1890 | Repair of leaking aneurysm of thoracic aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6461 | Tendon transfer of toe – bilateral | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2952 | Excison of acoustic neuroma (vestibular schwannoma) - tumours less than 2.5cm (performed by single surgeon) | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4520 | Excision of lesion of cornea | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7810 | Open arthrolysis of shoulder contracture +/- manipulation/injection | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A8480 | Transtympanic electrocochleography | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6510 | Carpal tunnel release (open) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR252 | Venoplasty | Major | £500.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4030 | Tracheoplasty | Major | £1,000.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5180 | Aorto-bifemoral bypass | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2954 | Excision of acoustic neuroma (vestibular schwannoma) - tumours managed by combined oto-neurosurgical team irrespective of tumour size | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3332 | Anterior resection - high (i.e. colorectal anastomosis above the peritoneal reflection) | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P1300 | Operations on female perineum | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0300 | Multiple procedures on forefoot, distal to and including the tarsometatarsal joints, which involves at least two distinct procedures not intrinsic to each other | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4600 | Off-pump coronary artery bypass (OPCAB) | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1432 | FESS Uncinectomy, ethmoidectomy, antrostomy or antral puncture inc polypectomy and attention to turbinates etc | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P1920 | Excision of septum of vagina | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3100 | Laparoscopic biliary gastric bypass | Complex | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6710 | Cubital tunnel release (open) (without transposition) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8700 | Excision biopsy of lymph node for diagnosis (cervical, inguinal, axillary) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1040 | Suture of eyebrow | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2510 | Repair of vesicovaginal fistula (including cystoscopy) | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2400 | Transthoracic fundoplication and gastroplasty | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S2503 | Local flap ? 9cm2 or more (including graft/flap to secondary defect) | Xmajor | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0880 | Amputation through mid-carpal/transmetacarpal | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1930 | Alveolar bone graft - unilateral | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0260 | Excision of arteriovenous malformation from vessels of brain | Complex | £1,900.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0740 | Total abdominal hysterectomy (+/- oophorectomy) +/- ureterolysis | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1920 | Primary open reduction of long bone with fixation | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0810 | Resection of rib and open drainage of pleural cavity | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.12 | General | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C8650 | Fluorescein angiography of eye (including ocular photography) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2110 | Temporomandibular meniscectomy | Major | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4930 | Revisional shoulder hemiarthroplasty | Xmajor | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7930 | Repair of abductor mechanism of hip | Major | £200.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7880 | Open or arthroscopic release of ankle joint contracture (excluding Achilles tendon lengthening) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A3200 | Decompression of cranial nerve (craniotomy) | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.7 | Teeth | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F1810 | Enucleation of cyst of jaw | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2050 | Tympanic neurectomy | Xmajor | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR142 | Bilateral stereotactic core biopsy of breasts | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5110 | Excision of intradural lesion | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0850 | Partial excision of bone (including exostoses) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5533 | Dressing of burn of skin or subcutaneous tissue - 2% - 10% | Minor | £150.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5020 | Repair of anal sphincter (including sigmoidoscopy) | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X2262 | Complex open reduction for congenital dislocation of hip (i.e. pelvic and femoral or Pemberton osteotomy or revision of open reduction) | Complex | £1,300.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2320 | Transthoracic repair of diaphragmatic hernia (acquired) | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7620 | Free functioning muscle transfer (as sole procedure) including closure of secondary defect | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5710 | Ablation of atrio-ventricular junction (including mapping) | Xmajor | £850.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4430 | Examination of rectum under anaesthetic (as sole procedure) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7340 | Repair of urethrorectal fistula | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8520 | Block dissection of axillary lymph nodes (axillary clearance levels 1-3) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5560 | OK (Outerbridge and Kashiwagi) procedure | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.3 | Duodenum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G5010 | Open excision of congenital lesion of duodenum including malrotation | Complex | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.4 | Small intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G6100 | Bypass of jejunum | Major | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4000 | Combined anterior and posterior correction and instrumentation, +/- fusion of idiopathic juvenile scoliosis (including spinal monitoring) | Complex | £2,500.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2650 | Suture of tongue | Intermediate | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7900 | Ileoscopy via stoma with therapy | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7420 | Autograft anterior cruciate ligament reconstruction (including arthroscopic and meniscectomy) | Xmajor | £750.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR910 | Insertion of central venous catheter - non-tunnelled (X-ray guided) | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4010 | Pyloromyotomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR254 | Angioplasty of other arteries (e.g. sub-clavian, tibial, femoro-popliteal) including peripheral angiogram +/- insertion of stent | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0140 | Excision of preauricular sinus | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G6082 | Open resectionof small intestine tumour | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J6730 | Endoscopic upper gastrointestinal ultrasound, eg for pancreaticobiliary diagnosis/transmucosal biopsy | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5740 | Ablation of ventricular arrhythmia (including mapping) | Complex | £1,350.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3365 | Laparascopic anterior resection - low (ie colorectal anastomosis at or below the peritoneal reflection) | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| H5100 | Haemorrhoidectomy (including sigmoidoscopy) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0210 | Excision of lesion of pinna | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5600 | Therapeutic endoscopic operations on outlet of female bladder (including cystoscopy) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S3622 | Full thickness graft, trunk and limbs – up to 9cm2 in area | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0312 | Primary closure of cleft lip - unilateral | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3102 | Revisional combined anterior discectomy and posterior fusion (thoracic region) Including Spinal Cord Monitoring | Complex | £1,600.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4832 | Implantation of spinal cord stimulator | Major | £1,300.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1150 | Removal of internal fixation and/or inter-maxillary fixation from jaw | Minor | £200.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| R2510 | Caesarean hysterectomy | Xmajor | £750.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2080 | Unilateral replantation of ureter into bladder (including cystoscopy) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0610 | Open removal of calculi from kidney | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.7 | Teeth | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0260 | Rhinoplasty following trauma or excision of tumour (including attention to turbinates) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6030 | Revision or conversion to arthrodesis of shoulder | Xmajor | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0320 | Exploratory thoracotomy | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0922 | VATS oesophageal / oesophagogastric myotomy | Major | £600.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2988 | Reconstruction of breast using ALT (anteriolateral thigh) flap including delayed reconstruction | Complex | £2,750.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0814 | Open biopsy of native kidney | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7330 | Closure of fistula of urethra (including cystoscopy) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3362 | Hartmann's procedure | Xmajor | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR352 | Embolisation of artery/vein | Major | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S2500 | Local flap ? less than 9cm2 | Major | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1420 | Graft of skin to eyelid | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4302 | Combined anterior vertebrectomy with posterior fusion and instrumentation | Complex | £2,500.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9113 | Percutaneous insertion of central venous dialysis line | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4230 | Mini-tracheostomy (percutaneous) | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2840 | Repair of avulsion of penis | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2700 | Fixation of epiphysis, including epiphysiodesis, correction of angular deformity | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6600 | Closed reduction of dislocated hip prosthesis | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Y3810 | Insertion of indwelling pleural catheter | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4812 | Insertion of skin expander into tissue (not related to breast reconstruction) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.6 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0610 | Excision of pineal gland | Complex | £1,900.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1620 | Plication of paralysed diaphragm | Xmajor | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7010 | Implantation of neurostimulator to peripheral nerve | Major | £550.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1140 | Correction of telecanthus | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 4.5 | Conjuctiva | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3950 | Radiotherapy to conjunctival lesion | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2540 | Replacement of mitral valve with sub-valve preservation (including biopsies) | Complex | £2,000.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT222 | Insertion and removal of high dose rate radioactive agent (brachytherapy) into prostate tumour | £800.00 | £571.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2954 | Excision of acoustic neuroma (vestibular schwannoma) - tumours managed by combined oto-neurosurgical team irrespective of tumour size | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2987 | Reconstruction of breast using Transverse Upper Gracilis (TUG) flap (including delayed reconstruction and nipple reconstruction) | Complex | £2,750.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR516 | Angioplasty of iliac artery, +/- insertion of stent | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S6400 | Excision of nail bed (Zadik's) (including anaesthetic) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8602 | Therapeutic arthroscopy of wrist joint (sole procedure) | Major | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X4810 | Change of cast without general anaesthetic (as sole procedure) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2613 | Revision of aortic valve replacement | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5620 | Lateral sphincterotomy of anus | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J3900 | Therapeutic ERCP with insertion of biliary or pancreatic stent(s), sphincterotomy or stone extraction | Major | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6910 | Tenolysis, of extensor, not otherwise specified | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0432 | Isolated sub talar fusion or mid foot fusion with autogenous graft (adult) | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3180 | Implantation of prosthesis into breast as sole procedure | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K0700 | Correction of total anomalous pulmonary venous connection | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3420 | Laparoscopic cystectomy (with construction of intestinal conduit or bladder) (including cystoscopy) | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 12.6 | Genitalia | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N0680 | Orchidectomy and excision of spermatic cord (+/- insertion of prosthesis) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1220 | Drainage of pleural cavity | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.8 | Spine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR530 | Fluoroscopically guided percutaneous vertebroplasty | Major | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7314 | Repair of distal hypospadia | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6213 | Soft tissue operations in the region of the greater trochanter (trochanteric bursitis, snapping hip) | Major | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1710 | Suture of eyelid (laceration) (as sole procedure) | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0800 | Other open operations on kidney | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.4 | Palate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 6.8 | Neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9400 | Operations on branchial cyst | Intermediate | £400.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6810 | Neurolysis and transposition of peripheral nerve (excludes carpal tunnel release) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2720 | Proximal gastric vagotomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2530 | Repair of rectovaginal fistula | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6914 | Tenolysis of extensor tendon of hand | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6763 | Repair of tendon of foot – extensor Minor | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7530 | Repair of lateral collateral ligament complex | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4930 | Removal of skin expander or valve (not related to breast reconstruction) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.8 | Spine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR500 | Chemonucleolysis | Intermediate | £350.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25100 | Coeliac plexus block, splanchnic nerve block, hypogastric block - diagnostic +/- Image Guidance | Intermediate | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6402 | Repair of major nerve | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7530 | Closure of ileostomy (as sole procedure) | Intermediate | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT210 | Oral introduction of liquid radioactive agent (brachytherapy) for thyroid tumour ablation | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5530 | Lumbar puncture (including spinal manometry) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9111 | Manipulation of joint (including intra-articular injection) for “Frozen Shoulder” (as sole procedure) – bilateral | Intermediate | £200.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5502 | Interposition arthroplasty of elbow | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2331 | Laparoscopic repair of hiatus hernia with anti-reflux procedure (eg fundoplication) | Major | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2430 | Revisional posterior decompression with fusion (thoracic region) Including Spinal Cord Monitoring | Complex | £1,300.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9017 | Yttrium joint injection (with radioactive precautions) | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.11 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X5020 | External cardioversion | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6017 | Ankle arthrodesis with internal fixation (arthroscopic) | Intermediate | £750.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2910 | Total laryngectomy | Complex | £2,000.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7881 | Release of contracture of interphalangeal joint of finger (excluding trigger finger or Dupuytren's disease) | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3180 | Free composite (ie including bone) vascularised grafts | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5300 | Open operations on iliac artery | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1890 | Repair of leaking aneurysm of thoracic aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7620 | Removal of foreign body from urethra | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2310 | Excision of cardiac tumour | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K3100 | Open valvotomy | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.10 | Great Vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1910 | Elective repair of aneurysm of ascending aorta | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0410 | Drainage of haematoma/abscess of pinna | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8240 | Meniscal allograft transplantation | Xmajor | £800.00 | £389.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2202 | Ureterostomy - formation | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0283 | Total excision of trapezium with spacer | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q3900 | Laparoscopy (including e.g. puncture of ovarian cysts, +/- biopsy, minor endometriosis, +/- ureterolysis) | Intermediate | £360.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0642 | Excision of lesion of skin or subcutaneous tissue - four or more, Head & Neck (excluding lipoma) | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25020 | Intravenous regional sympathetic block (guanethidine block) - 1 injection | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5534 | Dressing of burn of skin or subcutaneous tissue - 10% - 25% | Minor | £150.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1700 | Shelf augmentation of acetabulum, eg Wainwright or Trillat | Xmajor | £700.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2660 | Tongue flap - first stage and second stage | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9181 | Removal of Portacath/vasoport unit | Minor | £350.00 | £71.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X3770 | Intramuscular injection with X-ray control (eg piriformis block) | Minor | £150.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7981 | Extensive, greater than 2cm tear repair of large muscle including arthroscopic (excluding rotator cuff) | Major | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.5 | Mouth cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4230 | Removal of excess mucosa from mouth | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25030 | Stellate ganglion block (neurolytic) +/- Image Guidance | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1380 | Percutaneous tru-cut needle biopsy of lesion of kidney | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T4130 | Freeing of adhesions of peritoneum | Major | £350.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.8 | Major vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7920 | Plication of vena cava | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22000 | Routine electroencephalography (EEG) in adult or child aged over 5 (including reporting) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.4 | Palate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6018 | Ankle arthrodesis – revision, including converstion from total ankle replacement | Intermediate | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S3530 | Split autograft of skin, trunk and limbs – over 25cm2 and up to 5% of body surface area | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4800 | Therapeutic bronchoscopy (including laser, cryotherapy, lavage, snare, dilatation of stricture, insertion of stent) | Minor | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6030 | Transection of peripheral nerve for neuroma | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6820 | Secondary repair or reconstruction of extensor of hand/forearm | Major | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.11 | Retina | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C8440 | Retinal examination under anaesthetic including retinopexy if necessary | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25010 | Paravertebral block up to two levels (without X-ray control) | £120.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1300 | Introduction of substance into pleural cavity with chest drain | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4830 | Therapeutic sialendoscopy (including washout) | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0730 | Removal of foreign body from external auditory canal (and bilateral) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F5110 | Open extraction of calculus from parotid duct | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2984 | Reconstruction of breast using pedicled TRAM (including delayed reconstruction) | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1300 | Maintenance of cerebroventricular shunt | Major | £430.00 | £253.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0520 | Microscopically controlled excision of lesion of skin or subcutaneous tissue (Mohs micrographic surgery) with immediate reconstruction | Xmajor | £850.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.8 | Neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8723 | Selective dissection of cervical lymph nodes, levels 1 to 5 (+/- 6) | Complex | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1700 | Intra abdominal manipulation of colon for intussusception (as sole procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2303 | Coarctation repair involving prosthetic graft | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7500 | Lumbar sympathectomy diagnostic (local anaesthetic under X-ray control) | Intermediate | £300.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6710 | Cubital tunnel release (open) (without transposition) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8621 | Ultrasound-guided foam Sclerotherapy for varicose vein(s) ? bilateral | Intermediate | £300.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L0900 | Formation of cavo-pulmonary shunt (Glenn) | Complex | £1,300.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6620 | Endoscopic incision of outlet of male bladder (with cystoscopy) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1410 | Needle biopsy of pleura | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.12 | Urinary | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR630 | Percutaneous nephrostomy | Intermediate | £410.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6402 | Repair of major nerve | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7420 | Creation of arteriovenous fistula (including subsequent closure) | Intermediate | £400.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2920 | Endoscopic insertion/removal of prosthesis into ureter (including bilateral and cystoscopy, +/- pyelography) | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6900 | Revision of release of peripheral nerve | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0910 | Endoscopic fragmentation of calculi of kidney (including cystoscopy and insertion/removal of stent) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1082 | Partial maxillectomy for malignancy | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2952 | Laryngofissure | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6180 | Radical prostatectomy, reconstruction of bladder neck including bilateral pelvic lymphadenectomy (including cystoscopy) | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4080 | Injection of bulking agents for faecal incontinence | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6800 | Delayed or secondary repair of tendon (including graft, transfer and/or prosthesis) (not otherwise specified) | Major | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0680 | Drainage of pyonephrosis | Intermediate | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8300 | Therapeutic arthroscopy operation on articular cartilage (other than W8200 and W8230) (as sole procedure) | Intermediate | £350.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5120 | Intravascular ultrasound of coronary arteries (as sole procedure) | Major | £400.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8580 | Block dissection of pelvic lymph nodes (as sole procedure) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1870 | Drainage of petrous apex for sepsis | Complex | £1,400.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1330 | Biopsy of lesion of facial bone | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3602 | Enterocystoplasty (including cystoscopy) | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.1 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L3710 | Bypass of subclavian artery from the arch | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5535 | Dressing of burn of skin or subcutaneous tissue - greater than 25% | Minor | £150.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1990 | Elective repair of aneurysm of thoracic aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S3100 | Re-exploration of free flap | Xmajor | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E6310 | Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal masses | Major | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8880 | Arthroscopy of elbow (as sole procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7600 | Lumbar sympathectomy therapeutic (neurolytic under X-ray control) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7604 | Vein/artery graft of part of microvascular free tissue transfer | Major | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0750 | Amputation of arm | Major | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3180 | Revision of squint surgery | Xmajor | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4310 | Endoscopic transection of bladder (including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2382 | Aortic root replacement with valve conduit or homograft and/or remodelling | Complex | £1,900.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1644 | Open reduction/internal fixation of both columns of acetabulum | Complex | £1,000.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5532 | Thoracotomy and lung biopsy as sole procedure | Intermediate | £400.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1640 | Repair of congenital diaphragmatic hernia | Xmajor | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5210 | Endarterectomy and patch repair of iliac artery | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0210 | Hemihepatectomy (resection of four or more segments) +/- cholecystectomy | Complex | £1,900.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5930 | Fusion of digit joint(s) of hand with or without graft and with or without internal fixation | Intermediate | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5592 | VATS lung volume reduction - unilateral | Complex | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6013 | Primary arthrodesis of hip joint with or without graft and with or without internal fixation – hip | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J3500 | Sphincterotomy of bile duct and pancreatic duct using duodenal approach | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7910 | Metatarsal osteotomy (e.g. scarf) for Hallux valgus, +/- internal fixation and soft tissue correction | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2112 | Laparoscopic repair of recurrent inguinal hernia - bilateral | Intermediate | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3900 | Open removal of calculus from bladder (including cystoscopy) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8950 | Repair of peri-lymph fistula | Major | £550.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3580 | Laparoscopic closure of peptic ulcer | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1812 | Correction of ptosis of eyelid - complex | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0132 | Excision of chest wall tumour - with chest wall reconstruction | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1000 | Prosthesis of testis (insertion or removal) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8600 | Therapeutic arthroscopy operation on cavity of joint (not otherwise specified) (as sole procedure) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J1400 | Open puncture of liver | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3610 | Gastropexy for reflux | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7682 | Presacral sympathectomy - diagnostic | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2630 | Osseous labyrinthectomy | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4650 | Revision of corneal graft/wound | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1990 | Elective repair of aneurysm of thoracic aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0813 | Total thyroidectomy including block dissection of lymph nodes | Major | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5800 | Drainage through perineal region (including ischiorectal abscess) (including sigmoidoscopy) | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3202 | Open reduction and internal fixation wedge reconstruction bone graft scaphoid non-union | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0300 | Sub-total oesophagectomy with anastomosis in neck | Complex | £1,900.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5540 | Debridement of infected total joint replacement | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2290 | Excision of infected aortic graft with bypass | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N0700 | Excision of lesion of testis | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T3010 | Laparotomy for postoperative haemorrhage | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6711 | Cubital tunnel release (open) bilateral (without transposition) | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1911 | Core decompression of hip | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2330 | Removal of lesion of para-pharyngeal space | Major | £1,300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.1 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L3711 | Bypass of subclavian artery - extra-thoracic | Complex | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0861 | Metatarso-phalangeal cheilectomy - bilateral, as sole procedure | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0400 | Open excision of lesion of oesophagus | Major | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4600 | Prosthetic replacement of head of femur | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| X2200 | Closed reduction and Frog POP for congenital dislocation of hip (including dynamic arthrogram, traction and soft tissue release) | Major | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1910 | Total pharyngectomy | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2210 | Total glossectomy | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8620 | Therapeutic arthroscopy examination of hip joint, +/- biopsy | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8515 | Endovenous laser treatment (EVLT) of more than one venous trunk +/-phlebectomies - bilateral | Major | £600.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3780 | Injection of botulinum toxin into extraocular or periocular muscles | Intermediate | £300.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0104 | Transplantation of kidney into patient with abnormal, augmented or absent bladder | Xmajor | £1,500.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0380 | Nasal septum cauterisation (and bilateral) | Minor | £100.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22024 | Recording and reporting on electromyography and nerve conduction studies (EMG); Mononeuritis Multiplex, MND-AHC, Multiple Muscle Monitoring (eg Torticollis), Myaesthenia Gravis (- SFEMG) | Minor | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S1740 | Large myocutaneous (muscular/cutaneous) flap (9cm2 or more) including closure of secondary defect | Xmajor | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J2720 | Partial excision of bile duct and anastomosis of bile duct to duodenum/jejunum | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1813 | Correction of ptosis of eyelid with autologous fascia lata | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.8 | Neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8510 | Radical dissection of cervical lymph nodes | Complex | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0930 | Amputation of leg/foot (including Symes Lisfranc and Chopart) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4640 | Descemets stripping endothelial keratoplasty (DSEK) | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0830 | Total thyroid lobectomy and isthmectomy | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7860 | Arthroscopic arthrolysis of elbow (as sole procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8620 | Sampling of axillary lymph nodes | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.12 | Urinary | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR640 | Percutaneous creation of track to kidney for nephrolithotomy +/- insertion of stent | Xmajor | £800.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| AA460 | Destruction of branch of trigeminal nerve (neurolytic/RF/cryoprobe) | Intermediate | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2730 | Ureteroscopic extraction of calculus of ureter (including cystoscopy and insertion/removal of stent) | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4100 | Posterior correction of idiopathic juvenile scoliosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | £2,500.00 | £1,299.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7316 | Complex secondary repair of hypospadias | Xmajor | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7530 | Removal of lens implant | Intermediate | £200.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2952 | Excison of acoustic neuroma (vestibular schwannoma) - tumours less than 2.5cm (performed by single surgeon) | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4230 | Secondary suture of skin | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2880 | Excision biopsy of breast lesion after localisation | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.6 | Dilatation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR450 | Dilatation of stricture under imaging control | Intermediate | £360.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0920 | Myomectomy (including laparoscopically) +/- ureterolysis | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4120 | Anterior correction of idiopathic juvenile scoliosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | £2,500.00 | £1,299.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6582 | Transperineal template-guided biopsies of the prostate under image guidance | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X2260 | Open reduction and Frog POP for congenital dislocation of hip (including traction and innominate/femoral osteotomy) | Complex | £1,000.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q4400 | Ovarian cystectomy +/- omental biopsy (as sole procedure and including bilateral) | Major | £520.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0640 | Closure of bypass of oesophagus | Major | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6810 | Delayed or Secondary Repair Of Achilles Tendon Without Tendon Or Fascial Graft | Major | £550.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0132 | Excision accessory auricle/preauricular appendage | Minor | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4712 | Bladder instillation of pharmacologic agent (including cystoscopy) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6980 | Tenolysis, of flexor tendon (not otherwise specified) | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4320 | Endoscopic hydrostatic distention of bladder (including cystoscopy) | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2915 | Reconstruction of breast using extended latissimus dorsi flap (including delayed reconstruction) | Complex | £1,400.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22005 | 24 hour video telemetry Electroencephalography (EEG) (Including reporting) | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2210 | Open correction vesicoureteric reflux-unilateral | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7310 | Biopsy of peripheral nerve | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S3532 | Split autograft of skin, trunk and limbs – each additional 5% of body surface area | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6533 | Holmium Laser Enucleation of Prostatic Adenoma (HoLEP) | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2480 | Endoscopic operation(s) on pharyngeal pouch (e.g. Dohlman's procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5432 | VATS lobectomy | Major | £600.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5910 | Femoro-femoral bypass | Complex | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2544 | Revision of posterior excision of disc prolapse (lumbar region) | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5042 | Primary repair of high/intermediate congenital ano-rectal anomaly | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.9 | Abdominal wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2730 | Repair of dorsal hernia including lumbar hernia | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4990 | Panendoscopy +/- incisional biopsy | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3010 | Application of external fixation to bone | Major | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4300 | Anterior vertebrectomy with decompression and implant | Complex | £2,500.00 | £1,299.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2985 | Reconstruction of breast using free TRAM (including delayed reconstruction | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4480 | Resection of bladder neck (including cystoscopy) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR968 | Colonic stent insertion | Major | £750.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6192 | Robotic assisted laparoscopic radical prostatectomy, reconstruction of bladder neck including bilateral pelvic lymphadenectomy (including cystoscopy) | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 12.6 | Genitalia | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4453 | Balloon kyphoplasty - greater than two levels | Xmajor | £900.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1260 | Image guided endoscopic frontal, sphenoid and/or ethmoid sinus surgery (FESS) and bilateral | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16.6 | Hand | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0710 | Forequarter amputation | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7940 | Internal urethrotomy (including cystoscopy +/- dilataion) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| R1210 | Transvaginal cerclage of cervix of gravid uterus | Minor | £230.00 | £181.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9040 | Injection(s) +/- aspiration, into joint, cyst, bursa | Minor | £50.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6450 | Removal of foreign body from iris | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| AA460 | Destruction of branch of trigeminal nerve (neurolytic/RF/cryoprobe) | Intermediate | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2991 | Laparoscopic mobilisation of the greater omentum for reconstruction of breast (including delayed reconstruction) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3620 | Open bone biopsy as sole procedure | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5560 | Release of burn scar contracture, head, neck, hands, feet and genitalia | Xmajor | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1280 | Introduction of a Mirena coil | £50.00 | £129.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7042 | Atrial switch procedure for transposition of great vessels | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8512 | Endovenous laser treatment (EVLT) of single venous trunk +/- phlebectomies - unilateral | Intermediate | £400.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1080 | Open operations/repair of pulmonary artery | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR100 | Fluoroscopically guided biopsy(ies) | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 17.12 | Urinary | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR650 | Percutaneous pyelolysis | Xmajor | £800.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2542 | Dacryocysto-rhinostomy (endoscopic/laser assisted), including insertion and later removal of tube | Xmajor | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2542 | Posterior excision of disc prolapse with undercutting facetectomy +/- decompression - lumbar region (1 or 2 levels) | Xmajor | £900.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2930 | Vertical hemi-laryngectomy | Complex | £1,000.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5202 | Dupuytren’s fasciectomy palm only | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5980 | Fusion of interphalangeal joint(s) of toe (including internal fixation) – bilateral | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1440 | Combined approach tympanoplasty - intact canal wall tympanoplasty | Major | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G8080 | Small bowel capsule endoscopy (including interpretation and evaluation) | Intermediate | £400.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7290 | Trigger point injection/Enthesis - one injection | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3050 | Adjustments to pin sites secondary for non-union/mal-union Minor | Minor | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5030 | Revision total shoulder replacement | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5510 | Total prosthetic replacement of elbow | Xmajor | £800.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0310 | Stereotactic biopsy of lesion or tissue of brain | Complex | £1,600.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7380 | Repair of rupture of urethra (including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1910 | Laparoscopic varicocelectomy | Major | £600.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2780 | Operation for Peyronie's disease (eg Nesbitt's) | Intermediate | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0280 | Laparoscopic appendicectomy | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0212 | Secondary correction of scolios-related chest wall deformity (posterior costoplasty) (as sole procedure) | Complex | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5730 | Ablation of atrial arrhythmia (including mapping) | Complex | £1,100.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.11 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2720 | Proximal gastric vagotomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.7 | Teeth | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7010 | Open embolectomy of artery | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5220 | Epidural injection (thoracic) | Intermediate | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0110 | Exenteration of orbit | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L0620 | Creation of communication between pulmonary artery and aorta | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2160 | Reconstruction of transplant ureter | Xmajor | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7410 | Multiple ligament reconstruction of knee including posterior cruciate ligament | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2652 | Revision posterior fusion +/- instrumentation (lumbar region) including spinal cord monitoring | Complex | £1,500.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3202 | Operations on ureteric orifice (including endoscopic) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22023 | Recording and reporting on electromyography and nerve conduction studies (EMG); Mononeuropathy (eg ulnar), Cx/Lumbar radiculopathy, Myopathy | Minor | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8150 | Arthrotomy of large joint, including removal of loose body from joint | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4510 | Diagnostic endoscopic examination of bladder (flexible cystoscopy) including any biopsy | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2300 | Pharyngeal myotomy | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| E3410 | Laser surgery to vocal cord (including microlaryngoscopy) | Intermediate | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.6 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0210 | Cryotherapy to pituitary gland | Xmajor | £700.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2340 | Transabdominal repair of diagphragmatic hernia (excluding hiatus hernia) | Complex | £800.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F5510 | Dilatation of parotid duct | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5520 | Open excision of lesion of lung | Complex | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4940 | Scapulo-thoracic fusion | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3945 | Open reduction and internal fixation for periprosthetic fracture around hip | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7122 | Ultrasound phacoemulsification of cataract, with lens implant - unilateral (including topical or local anaesthetic) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2932 | Cystoscopy and removal of transplant stent | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0360 | Septoplasty of nose (including attention to turbinates) | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.5 | Mouth cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4530 | Catheterless oesophageal pH monitoring (eg Bravo) | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 | Investigations | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20230 | Impedance audiogram | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.5 | Mouth cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4210 | Biopsy of lesion of mouth | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5100 | Combined abdominal and vaginal operations to support outlet of female bladder (including sling procedures) (including cystoscopy) | Major | £570.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.12 | General | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1880 | Repair of leaking aneurysm of arch of aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| L2600 | Percutaneous transluminal balloon operations on aorta | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0605 | Secondary excision of malignant lesion - trunk and limbs | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2890 | Ultrasound guided interstitial laser ablation of breast lesion | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1680 | Transluminal closure of atrial septal defect / patent foramen ovale | Complex | £800.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1910 | Simple excision of inguinal hernial sac (herniotomy) ? bilateral | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 64300 | Echocardiography (including reporting) as sole procedure | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7485 | Small joint (eg interphalangeal/metacarpo-phalangeal joint) ligament reconstruction | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8650 | Therapeutic sub-talar arthroscopy additional to synovectomy to gain vision | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4902 | Percutaneous transluminal angioplasty of coronary artery(ies) with intravascular ultrasound (including laser) | Complex | £900.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0830 | Closed reduction and fixation of fractured jaw | Intermediate | £200.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6700 | Release of entrapment of peripheral nerve | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.4 | Palate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F3070 | Suture of palate | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0750 | Subtotal abdominal hysterectomy (+/- oophorectomy) +/- ureterolysis | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6980 | Removal of foreign body from anterior chamber | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X4112 | Percutaneous insertion of Tenckhoff catheter | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7085 | Sacral nerve stimulation for faecal/urinary incontinence or constipation | Major | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0580 | Repair of compound fracture of cranium | Xmajor | £750.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J4300 | Diagnostic ERCP (includes forceps biopsy) | Intermediate | £360.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1520 | Suction clearance of middle ear (as sole procedure) | Minor | £50.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8.11 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 64302 | Transoesophageal echocardiography (including reporting) (as sole procedure) | Intermediate | £320.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0100 | Oesophagectomy/oesophagogastrectomy with anastomosis in chest | Complex | £1,900.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.6 | Rectum/anus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7032 | Haemorrhoidal artery ligation operation (including image-guided) +/- recto anal prolapse repair | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9110 | Insertion of tunnelled central venous catheter (Hickman Line) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2640 | Incision of lacrimal sac | Minor | £100.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3350 | Combined anterior approach discectomy, decompression and fusion and posterior fusion (lumbar region) including spinal cord monitoring | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7011 | Trial of neurostimulator to peripheral nerve (as sole procedure) not at time of permanent implant | Intermediate | £450.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3732 | Revision of uncemented or cemented total hip replacement without adjunctive procedures | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2220 | Biopsy of lesion of eyelid | Minor | £170.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6012 | Primary arthrodesis of joint with or without graft and with or without internal fixation – shoulder | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q2230 | Laparoscopic oophorectomy and salpingectomy, +/- biopsy eg. omentum, peritoneum, lymph node (as sole procedure) - bilateral | Major | £520.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2981 | Endoscopic vesico-ureteric anti-reflux procedure (and bilateral) (including cystoscopy) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.3 | Trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4032 | Tracheoplasty for congenital conditions | Complex | £1,000.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.8 | Heart – cardiac surgery | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1180 | Endovascular closure of perimembranous ventricular septal defect | Complex | £800.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2102 | Laparoscopic repair of recurrent inguinal hernia - unilateral | Intermediate | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1090 | Robotic assisted laparoscopic pyeloplasty | Complex | £1,000.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR290 | Cerebral angioplasty with or without insertion of metallic stent | Complex | £1,300.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2233 | Adrenalectomy - unilateral (laparoscopic) | Major | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR963 | Percutaneous chemical ablation of tumour - CT guided | Intermediate | £1,100.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8100 | Open excision of calcific deposit (eg shoulder, hip) | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0200 | Excision of lesion of tissue of brain | Complex | £1,600.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2880 | Repair of injury to penis | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4200 | Perineal repair of prolapse of rectum | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0810 | Polypectomy of internal nose (and bilateral, including endoscopic) | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2200 | Ureterostomy - closure | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1350 | Closure of oro-antral fistula with local flap | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1892 | Immediate repair of aortic dissection (ie within two weeks of happening) | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0440 | Division of adhesions of turbinate of nose (and bilateral) | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.11 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2780 | Vagotomy and pyloroplasty | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2702 | Epiphysiolysis (eg Langenskiold procedure) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8540 | Radiofrequency ablation of more than one venous trunk +/- phlebectomies - unilateral | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1581 | Laparoscopic colostomy and stoma formation (including revision) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7280 | Urethral valve resection | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.8 | Spine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR540 | CT guided percutaneous vertebroplasty | Complex | £900.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2511 | Excision of ureterocele (with or without ureteric reimplantation) - bilateral | Xmajor | £750.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.10 | Vitreous | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7922 | Pars plana vitrectomy/vitreous biopsy | Major | £550.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5180 | Revision combined abdominal and vaginal operations to support outlet of female bladder (including sling procedures and cystoscopy) | Xmajor | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S3624 | Full thickness graft, head, neck, hands and genitalia – up to 9cm2 in area | Major | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Y3820 | Insertion of indwelling psoas catheter | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25020 | Intravenous regional sympathetic block (guanethidine block) - 1 injection | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5100 | Combined abdominal and vaginal operations to support outlet of female bladder (including sling procedures)(including cystoscopy) | Major | £570.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1200 | Norwood stage 1 procedure | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0180 | Excision of abscess of brain | Complex | £1,300.00 | £785.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6150 | Revision of previous glaucoma surgery (including topical local anaesthetic) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0251 | Nephrectomy - bilateral | Major | £750.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5705 | Thoracotomy pleurectomy/pleurodesis +/- ligation of bullae for pneumothorax | Xmajor | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2680 | Revision anterior discectomy, decompression and anterior fusion +/- intrumentation (lumbar region) including spinal cord monitoring | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P0600 | Excision of lesion of vulva | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.10 | Vitreous | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7920 | Pars plana vitrectomy with internal tamponade, scleral buckling and retinopexy without dissection or excision of epiretinal membrane/macular surgery | Xmajor | £650.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1230 | Core biopsy of thyroid gland | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4420 | Endoscopic extraction of calculus of bladder (including cystoscopy) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3100 | Combined anterior discectomy and posterior fusion (thoracic region) Including Spinal Cord Monitoring | Complex | £1,300.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0602 | Primary excision of malignant lesion - head and neck | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5512 | Prosthetic replacement of radial head | Xmajor | £800.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5702 | Thoracotomy lung volume reduction - unilateral | Complex | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0700 | Right hemicolectomy | Xmajor | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9180 | Insertion of implantable central venous port (portacath) e.g Port-a-Cath under image guidance | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1910 | Primary reduction of fracture of neck of femur and internal fixation | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR967 | CT guided thermocoagulation of osteoid osteoma | Complex | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3015 | Reconstruction of breast using fixed prosthesis (including delayed reconstruction) | Major | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0890 | Excision distal clavicle, as sole procedure | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W8820 | Diagnostic arthroscopic examination of shoulder joint, with or without biopsy (as sole procedure) | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5593 | VATS lung volume reduction - bilateral | Complex | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2780 | Simple mastectomy (including axillary node biopsy) – unilateral | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2500 | Closed reduction of fracture of long bone with external fixation (excluding fixation by cast or percutaneous K-wires) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1640 | Simple pelvic osteotomy and fixation eg Salter or Chiari osteotomies | Major | £1,000.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S1510 | Needle/tru-cut biopsy of muscle (as sole procedure) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7402 | Open formation of ileostomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1640 | Repair of congenital diaphragmatic hernia | Xmajor | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3440 | Microdochotomy | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7010 | Percutaneous tenotomy | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.5 | Mouth cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F3810 | Excision/destruction of lesion of mouth | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0607 | Photodynamic therapy (PDT) to malignant lesion of skin - four or more | Major | £250.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR121 | Unilateral image guided vacuum assisted excision of breast lesion (with biopsy) | Intermediate | £320.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 17.2 | Drainage | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR180 | Ultrasound guided drainage of fluid collection | Intermediate | £400.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5582 | Diathermy of urethral caruncle | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6014 | Primary arthrodesis of knee joint with or without graft and with or without internal fixation | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1080 | Laparoscopic pyeloplasty | Complex | £1,000.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9240 | Examination/ manipulation of joint under general anaesthetic +/- injection +/- arthrogram (as sole procedure) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1000 | Closure of defect of interatrial septum (secundum Atrial Septal Defect or Patent Foramen Ovale) | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7510 | Thorascopic cervical sympathectomy | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8514 | Endovenous laser treatment (EVLT) of more than one venous trunk +/- phlebectomies - unilateral | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0500 | Bypass of oesophagus | Xmajor | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8003 | Major release of muscle for pain or contracture (eg Quadriceps) (involving large joint) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0100 | Oesophagectomy/oesophagogastrectomy with anastomosis in chest | Complex | £1,900.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.3 | Trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3900 | Partial excision of trachea with reconstruction | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6082 | Removal of pacing system (generator only) | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3595 | Excision of mammary fistula | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0850 | Removal of foreign body from cavity of nose | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F5010 | Transposition of parotid duct (including bilateral) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6100 | Insertion of single chamber implantable cardioverter defibrillator (ICD) | Complex | £1,000.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.11 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1900 | Middle ear tumour excision | Major | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1010 | Excision of lesion of eyebrow | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR270 | Angioplasty with insertion of metallic stent-graft | Major | £550.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1703 | Impedance controlled bipolar radiofrequency ablation for menorrhagia including hysteroscopy | Major | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N0630 | Laparoscopic orchidectomy | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| N1520 | Unilateral epididymectomy | Minor | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 | Abdominal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2200 | Revision of prosthesis of abdominal aorta | Complex | £2,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H2510 | Rigid sigmoidoscopy including proctoscopy and biopsy | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8520 | Arthroscopy of knee (including examination under anaesthetic, washout and biopsy) (as sole procedure) | Intermediate | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1060 | Revision of mastoidectomy (including meatoplasty) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0434 | Isolated sub talar fusion or mid foot fusion without autogenous graft (adult) | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W7980 | Metatarsal osteotomy (e.g. scarf) for Hallux valgus, +/- internal fixation and soft tissue correction - bilateral | Xmajor | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2562 | Decompression for central spinal stenosis (three or more levels) | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6300 | Graft to peripheral nerve | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6710 | Cyclodialysis (separation of ciliary body) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0910 | Open reduction and fixation of nasal ethmoidal fracture | Complex | £800.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L6230 | Reconstruction/bypass for popliteal aneurysm | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G6500 | Diagnostic eosophago-gastro-duodenoscopy (OGD) includes forceps biopsy, biopsy urease test and dye spray | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16.6 | Hand | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6750 | Primary repair of flexor of hand (excluding Zone II) | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3334 | Anterior resection - low (ie colorectal anastomosis at or below the peritoneal reflection | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L6840 | Repair of limb artery using vein graft | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5442 | VATS wedge resection of lung | Major | £600.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.4 | Palate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F3240 | Operations on uvula | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0880 | Open drainage of perinephric abscess | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1880 | Repair of leaking aneurysm of arch of aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4020 | Surgery for correction of congenital intestinal atresias | Xmajor | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6523 | Primary open reduction of dislocation of large joint | Intermediate | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2000 | Excision of lesion of vagina (e.g. warts and cysts) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1310 | Antral puncture and wash-out (and bilateral) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 | Investigations | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20220 | Pure tone audiogram (air and bone conduction) - including masking | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2610 | Excision/biopsy of lacrimal sac | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1460 | Trephining of frontal sinus and bilateral | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0513 | Interpositional silastic arthroplasty of MCP/PIP joints - multiple | Major | £600.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0420 | Reduction turbinates of nose (trim, radical excision) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0510 | Excision of lesion of cranium | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2190 | Replacement of graft of thoraco-abdominal aneurysm | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4900 | Destruction of lesion of anus | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8600 | Unilateral varicose vein injection sclerotherapy | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8510 | Ligation/stripping of long or short saphenous vein (including local excision/multiple phlebectomy) | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0900 | Implantation of neurostimulator to brain | Major | £560.00 | £311.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V5002 | Manipulation of spine under GA/IV sedation (sole procedure) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6302 | Graft to major nerve | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 | Investigations | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20240 | Impedance audiogram as part of other procedure | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5700 | Excision arthroplasty of first metatarso-phalangeal joint with prosthetic implantation or interposition arthroplasty | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K0930 | Closure of partial atrioventricular septal defect | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.5 | Mouth cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6913 | Total synovectomy of large joint | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.7 | Sclera | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5720 | Repair of scleral laceration | Intermediate | £200.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S1700 | Distant flap ? delay/division/inset | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| R2120 | Forceps cephalic delivery | Intermediate | £300.00 | £187.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A8460 | Static single measurement of muscle compartment pressures (Including reporting) | Minor | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M8120 | Meatoplasty | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0110 | Excision of vermilion border of lip and advance of mucosa of lip | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1330 | Intranasal antrostomy including endoscopic and antral washout (including bilateral) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.11 | Liver | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR576 | Biliary drainage with occluded stent in place | Major | £750.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 | Abdominal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1620 | Axillo-unifemoral bypass | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0512 | Interpositional silastic arthroplasty of MCP/PIP joints – single | Major | £600.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K0400 | Correction of tetralogy of Fallot | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7430 | Reconstruction of lateral collateral ligament complex | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3310 | Abdominoperineal pull through resection with colo-anal anastomosis +/- colonic pouch and associated stoma | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0110 | Thoracoplasty | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2582 | Closed reduction of fracture of short bone (including cast or percutaneous K-wires) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W2830 | Removal of internal fixation from bone/joint, excluding K-wires +/- Image Guidance | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2200 | Primary repair of femoral hernia | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2612 | Replacement of aortic valve with homograft or stentless porcine | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7700 | Diagnostic endoscopic examination of urethra (as sole procedure) (including cystoscopy) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6220 | Excision of bursa | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8400 | Repair of knee ligaments (open or arthroscopic) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0300 | Sub-total oesophagectomy with anastomosis in neck | Complex | £1,900.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0940 | Percutaneous nephrolithotomy (including cystoscopy and retrograde catheterisation) | Complex | £1,000.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7603 | Microvascular free tissue transfer (as sole procedure including closure of secondary defect) | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1690 | Non-surgical reduction of myocardial septum (e.g. alcohol septal ablation) | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S7010 | Wedge excision or avulsion of nail (including chemical ablation of nail bed) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1320 | Osteotomy of proximal femur | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5920 | Surgical iridectomy | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3122 | Harvesting for autologous chondrocyte transplantation into knee including arthroscopy | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5230 | Excision plantar fibroma | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2312 | Transthoracic repair of paraoesophageal hiatus hernia | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7292 | Trigger point injection/Enthesis - more than one injection | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1240 | Pulmonary embolectomy | Complex | £1,600.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1700 | Therapeutic endoscopic operations on ventricle of brain (including examination and biopsy of lesion) | Xmajor | £700.00 | £311.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22004 | 24 hour ambulatory Electroencephalography (EEG) (Including reporting) | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2984 | Delayed reconstruction of breast using pedicled TRAM | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1032 | Thoracoscopy and drainage and chemical pleurodesis | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1645 | Open reduction/internal fixation plus bone graft symphysis pubis | Complex | £1,000.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0910 | Excision of lesion of external nose | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1810 | Correction of ptosis of eyelid - simple, including tarsomullerectomy | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2402 | Transthoracic fundoplication | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4210 | Tracheostomy | Intermediate | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4900 | Open biopsy of lesion of spine where no other operative procedure on the spine is performed. | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3390 | Reversal of Hartmann's procedure | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0320 | Revision of primary closure of cleft lip | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0700 | Cranio-facial resection | Complex | £1,600.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4410 | Total excision of parotid gland and preservation of facial nerve | Xmajor | £1,000.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1648 | Osteotomy/transfer of greater trochanter in isolation | Xmajor | £1,000.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G1400 | VATS excision lesion of oesophagus | Xmajor | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G8082 | Diagnostic oesophago-gastro-duodenoscopy (OGD) and immediate colonoscopy includes forceps biopsies, biopsy test and dye spray (as sole procedure) | Intermediate | £440.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3014 | Reconstruction of breast using expandable prosthesis (including delayed reconstruction) | Major | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1590 | Open formation of colostomy | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.6 | Rectum/anus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7020 | Transrectal sextant needle biopsy of prostate with ultrasound guidance | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 18 | Chemotherapy | |||||||||||||||||||||||||||||||||||||||||||||||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
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| 18.0. | Chemotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0004 | Clinical supervision and planning for delivery of chemotherapy And/Or Systemic Anti-Cancer Therapy for 1-28 Days | £500.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2910 | Application of skeletal traction to bone | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6110 | Excision of lesion of peripheral nerve (eg neurilemoma) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8580 | Block dissection of pelvic lymph nodes (as sole procedure) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0881 | Excision of joint of toe with release of contracture and soft tissue correction | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J3000 | Anastomosis of common bile duct | Major | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6480 | Operation to support outlet of male bladder (including sling procedures) (including cystoscopy) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2400 | Therapeutic endoscopic operation on pharynx | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3720 | Repair of vesicocolic fistula | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2280 | Open correction vesicoureteric reflux-bilateral | Xmajor | £1,000.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0510 | Open drainage of liver | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6762 | Repair of tendon of foot - flexor | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1422 | Extensive segmental excision of mandible | Xmajor | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £140.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.10 | Vitreous | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7982 | Pars plana vitrectomy with internal tamponade, scleral buckling and retinopexy with dissection or excision of epiretinal membrane/macular surgery | Complex | £1,300.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3710 | Cystourethroplasty (including cystoscopy) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3622 | Needle biopsy of bone as sole procedure | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4430 | Partial excision of parotid gland and preservation of facial nerve | Xmajor | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2012 | Laparoscopic repair of inguinal hernia - bilateral | Intermediate | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7715 | Corocoid bone block transfer for recurrent instability of shoulder (Bristow-Latarjet Procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6019 | Ankle syndesmosis reconstruction | Complex | £1,000.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7100 | Bypass of ileum | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0310 | Exploratory open craniotomy | Xmajor | £750.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5780 | Ablation of accessory pathway or selected modification of AV node (including mapping) | Complex | £1,100.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.7 | Sclera | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5730 | Scleral graft | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9020 | Sentinel node mapping and sampling with blue dye and radioactive probe for breast cancer | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9112 | Surgical insertion of central venous dialysis line | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6580 | Carpal tunnel release (open) - bilateral | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.3 | Meninges | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A3830 | Operation for arachnoidal cyst | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7320 | Repair of epispadias | Xmajor | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1420 | Myringoplasty | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2950 | Laryngofissure and cordectomy of vocal cord | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4850 | Implantation/removal of intrathecal drug delivery system | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1550 | Abdominal operation for Hirschprung's disease (eg Duhamel, Söave and Surcuson operations) | Complex | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S2502 | Local flap ? 9cm2 or more (excluding graft/flap to secondary defect) | Major | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2502 | Closed reduction of fracture of long bone, including cast or percutaneous K-wires | Intermediate | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7582 | Open surgical stabilisation of patella, including soft tissue/tendon transfer or release, +/- application of cast (child) | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J2900 | Anastomosis of hepatic duct | Complex | £1,300.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6230 | Laser iridotomy | Intermediate | £360.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S1500 | Biopsy of skin or subcutaneous tissue | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8592 | Laparoscopic retroperitoneal lymph node dissection | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22028 | Inpatient Sleep study (polysomnography) including reporting | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4780 | Aspiration of subcutaneous haematoma | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0632 | Prosthetic patello-femoral replacement (as sole procedure) | Major | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A8470 | Dynamic laboratory investigation involving measurement of muscle compartment pressures with manometer | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9000 | Sentinel node mapping and sampling with blue dye or radioactive probe for breast cancer | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0500 | Bypass of oesophagus | Xmajor | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T3410 | Open drainage of subphrenic abscess | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5750 | Internal cardioversion | Intermediate | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K6030 | Replacement of generator for intravenous cardiac pacemaker system (without lead change) | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7620 | Thoracic sympathectomy therapeutic (neurolytic under X-ray control) | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16.6 | Hand | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0820 | Partial amputation of digit | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3520 | Closure of perforated ulcer of stomach | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2350 | Revision operation on ascending aorta and proximal descending aorta | Complex | £2,000.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3600 | Enlargement of bladder (including cystoscopy) | Complex | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1892 | Immediate repair of aortic dissection (ie within two weeks of happening) | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9018 | Percutaneous biopsy/ arthrography/ aspiration in assessment of total hip replacement | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6711 | Cubital tunnel release (open) bilateral (without transposition) | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2550 | Lacrimal intubation (as sole procedure) | Intermediate | £150.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6520 | Paediatric cardiac catheterisation | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4720 | Drainage of lesion of skin (including abscess) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7332 | Closure of fistula of urethra after hypospadias | Major | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8680 | Bilateral varicose vein injection sclerotherapy | Intermediate | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5223 | Dupuytren’s dermofasciectomy and graft, or for recurrent disease – multiple digits | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3113 | Surgical correction of squint - bilateral | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7583 | Repair of patellar/quadricep tendon | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0300 | Stereotactic ablation of tissue of brain | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5000 | Primary total shoulder replacement | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0930 | Amputation of leg/foot (including Symes Lisfranc and Chopart) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9115 | Implantation of port device (PowerPort) | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.3 | Duodenum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G5100 | Bypass of duodenum | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.4 | Small intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G6000 | Open formation of jejunostomy | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.6 | Rectum/anus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3320 | Abdominoperineal resection of rectum and anus | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J1900 | Anastomosis of gall bladder (to another viscus) | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.9 | Thorax | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR595 | Insertion of tracheal/bronchial metallic stent | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0653 | Removal of benign lesion in muscle or deeper tissue (excluding lipoma) | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4440 | Excision of submandibular gland | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2330 | Transabdominal repair of hiatus hernia | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.4 | Small intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G5810 | Excision of jejunum | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0702 | Aural toilet (including microsuction and/or suction of exteriorised mastoid cavity) including bilateral | £50.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0330 | Biopsy of of septum of nose | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4350 | Exploration of conjunctiva (including removal of foreign body) | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4200 | Complex primary total knee replacement (ie including bone graft, augmentation or osteotomy) | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9114 | Removal of central venous dialysis line | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1220 | Fine needle aspiration of thyroid gland | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0210 | Nephrectomy and excision of perirenal tissue | Xmajor | £650.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1000 | Therapeutic endoscopic operations on kidney (including cystoscopy and retrograde catheterisation) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1220 | Creation of ventriculovascular anastomosis | Major | £560.00 | £311.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2830 | Re-excision of lesion of breast if resection margins are not clear (as sole procedure) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5080 | Repair of anal trauma | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N0920 | Orchidopexy | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L6300 | Transluminal procedures on femoral artery | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4010 | Mucosal graft to conjunctiva | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20140 | 24 hour ECG Holter (including reporting) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1647 | Open reduction/internal fixation of fractures of the greater trochanter, including fixation of non-union of greater trochanter after trochanteric osteotomy | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2030 | Removal of Grommets | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0910 | Open pleural biopsy as sole procedure | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V5210 | Chemonucleosis (multiple levels) | Intermediate | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0120 | Enucleation/evisceration of eyeball | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1513 | Correction of lower lid ectropion with graft/flap | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1083 | Hemi-maxillectomy for malignancy | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1250 | Thyroid: re-operation | Complex | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7530 | Laparoscopic lumbar sympathectomy | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5400 | transluminal operations on iliac artery | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3510 | Diverticulectomy of bladder | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4190 | Therapeutic High Resolution Anoscopy (HRA) in symptomatic patients (+/- biopsy or ablation of lesion of anus) | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2543 | Revision of posterior excision of disc prolapse with undercutting facetectomy (lumbar region) | Complex | £1,200.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7872 | Arthroscopic arthrolysis of shoulder contracture +/- manipulation/injection | Major | £600.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6532 | Holmium laser resection of prostate (HoLRP) (including cystoscopy) | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5910 | Iridocyclectomy | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3715 | Hip resurfacing arthroplasty | Xmajor | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2220 | Partial glossectomy for malignancy | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5932 | VATS lung biopsy | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7011 | Trial of neurostimulator to peripheral nerve (as sole procedure) not at time of permanent implant | Intermediate | £450.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8513 | Endovenous laser treatment (EVLT) of single venous trunk +/- phlebectomies - bilateral | Major | £600.00 | £389.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6400 | Repair of peripheral nerve | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6912 | Total synovectomy of small joint | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1370 | Endoscopic balloon dilation maxillary sinuplasty and bilateral | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5710 | Debridement of wound (and surgical toilet) - up to 25cm² in area | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8110 | Creation of peritoneovenous shunt (Levine/Denver) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G1900 | Rigid oesophagoscopy including any biopsy, laser or diathermy destruction of lesions | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3733 | Revision of total hip replacement including insertion of reconstruction rings, plates, screws, etc., and/or impaction bone grafting to acetabulum and/or femur | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5380 | Repair of ventricular aneurysm | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2500 | Diagnostic nasolaryngopharyngoscopy +/- biopsy +/- cautery | Minor | £50.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.11 | Liver | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR570 | Percutaneous insertion of plastic biliary endoprosthesis | Major | £500.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6762 | Photoselective vaporisation of prostate (KTP Laser PVP) (including cystoscopy) | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 12.6 | Genitalia | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2620 | Partial amputation of penis | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3220 | Revision of gastro–jejunostomy | Xmajor | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.9 | Abdominal wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2000 | Primary repair of inguinal hernia | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4800 | Therapeutic bronchoscopy (including laser, cryotherapy, lavage, snare, dilatation of stricture, insertion of stent) | Minor | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1510 | Bilateral epididymectomy | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.10 | Vitreous | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7923 | Intravitreal injection of pharmaceutical for neovascular age related macular degeneration | Minor | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR302 | Endovascular management of brain arteriovenous malformation (including 2 separate interventions) | Complex | £1,900.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0260 | Endoscopically assisted oesophagectomy | Complex | £1,900.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T4610 | Paracentesis abdominis for ascites | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.3 | Meninges | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4110 | Evacuation of subdural haematoma or abscess | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0315 | Primary closure of cleft lip - bilateral including anterior palate | Major | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3400 | Open excision of lesion of rectum and colon | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6015 | Implantation of biventricular pacemaker | Complex | £900.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4480 | Dilation of stricture of rectum | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1512 | Correction of lower lid ectropion without graft/flap | Intermediate | £360.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7500 | Excision of diverticulum of urethra (including cystoscopy) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1360 | Endoscopic balloon dilation frontal sinuplasty and bilateral | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.8 | Major vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7710 | Creation of portocaval shunt | Complex | £1,300.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4110 | Open excision of lesion from bladder (including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| M5222 | Laparoscopic colposuspension | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| P2510 | Repair of vesicovaginal fistula (including cystoscopy) | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0660 | Coccygectomy (multiple levels) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5250 | Circular stapling haemorrhoidectomy | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7190 | Extracapsular cataract extraction with implant - bilateral | Xmajor | £750.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0230 | Cauterisation of lesion of cervix uteri (+/- loop diathermy, colposcopy or polypectomy) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2600 | Replacement or repair of aortic valve | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P0310 | Excision of Bartholin gland | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5722 | Excision reconstruction of small joint | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8850 | Diagnostic subtalar arthroscopy including synovectomy to gain vision (as sole procedure) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q3800 | Laparoscopy and therapeutic procedures (including laser, diathermy and destruction e.g. endometriosis, adhesiolysis, tubal and ovarian surgery, +/-ureterolysis) | Major | £520.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4122 | Transanal endoscopic mircosurgery | Xmajor | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| H5510 | Laying open of low anal fistula (fistulotomy) (including sigmoidoscopy) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.9 | Abdominal wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2300 | Repair of recurrent femoral hernia | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5520 | Implantation of artificial urinary sphincter at bladder neck and/or removal (including cystoscopy) | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2430 | Transabdominal anti-reflux operations | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J3300 | Incision of bile duct (including exploration for calculus removal) | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0110 | Reconstructive cranioplasty | Xmajor | £750.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2580 | Closed reduction of fracture of short bone with external fixator | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0383 | Lateral petrosectomy (for tumour) | Complex | £1,350.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1910 | Middle ear polypectomy | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7780 | Revision stabilisation of shoulder joint | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T3930 | Surgical drainage of retroperitoneal abscess | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3340 | Primary anterior discectomy, decompression and anterior fusion +/- instrumentation lumbar region (1 or 2 levels) including spinal cord monitoring | Xmajor | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5723 | Excision reconstruction of large joint | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0610 | Total excision of cervical rib | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0100 | Amputation of cervix uteri | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2380 | Anterior (+/- posterior) colporrhaphy with vaginal hysterectomy (including primary repair of enterocele and cystoscopy) | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22022 | Recording and reporting on electromyography and nerve conduction studies (EMG); CTS (Bilateral upper limb only) or peripheral neuropathy | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4080 | Craniotomy – post-operative haemorrhage | Xmajor | £750.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0530 | Suture of lip | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6010 | Cardiac pacemaker system introduced through vein (dual chamber) | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.4 | Palate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X1430 | Posterior exenteration of pelvis | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| AA489 | Transtympanic chemical labrynthectomy | Minor | £150.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7480 | Posterior cruciate ligament reconstruction including arthroscopic | Xmajor | £700.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3122 | Revisional transthoracic/antero-lateral excision of intervertebral disc +/- fusion including spinal cord monitoring | Complex | £1,600.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.3 | Paraspinal injections | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25012 | Sacral root block (under X-ray control) | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4740 | Drainage of large subcutaneous abscess/haematoma | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0110 | Hemispherotomy | Complex | £2,000.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4452 | Balloon kyphoplasty - two level | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1430 | Removal of cerebroventricular shunt | Intermediate | £350.00 | £181.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6752 | Primary repair of flexor of hand in Zone II | Major | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6040 | Removal of pacing system with bypass | Complex | £1,900.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0740 | Repair of ruptured oesophagus | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1910 | Construction of ileal conduit including ureteric implantation | Xmajor | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1030 | Dilatation of cervix uteri and curettage of uterus including polypectomy and diathermy of cervix | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0710 | Decortication of pleura of lung | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4800 | Excision of lesion of anus | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2510 | Excision of ureterocele (with or without ureteric reimplantation) - unilateral | Major | £600.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7110 | Extracapsular cataract extraction without implant - unilateral | Major | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N3030 | Circumcision | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0820 | Bilateral subtotal thyroidectomy | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20132 | Exercise or dobutamine stress echocardiography (including ECG and reporting) | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7110 | Percutaneous transluminal angioplasty of artery, +/- insertion of stent | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0130 | Surgery for craniostenosis (single suture) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X2280 | Manipulation of hip and casting (as sole procedure) | Minor | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5200 | Unicompartmental knee replacement | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1523 | Correction of entropion - upper lid, including graft/flap | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1992 | Delayed repair of aortic dissection (ie more than two weeks after happening) | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1701 | Laparoscopic excision of endometriosis, +/-ureterolysis | Major | £580.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8722 | Selective dissection of cervical lymph nodes, levels 1 to 4 | Xmajor | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X1420 | Anterior exenteration of pelvis | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3580 | Laparoscopic rectopexy without mesh | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0122 | Enucleation/evisceration of eyeball (with implant) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1400 | Excision of mandible | Major | £550.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR960 | Percutaneous thermal coagulation of mass | Complex | £1,100.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1390 | Open femoro-acetabular surgery for hip impingement | Xmajor | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4210 | Total prosthetic replacement of knee joint, with or without cement, +/– patella | Xmajor | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5250 | Needle suspension of bladder neck (including cystoscopy) | Intermediate | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0001 | Clinical supervision and planning for the delivery of chemotherapy and/or systemic anti-cancer therapy for 0-7 Days | £125.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C8240 | Photodynamic therapy to the retina (PDT) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J1800 | Cholecystectomy (including mini-cholecystectomy) | Major | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1910 | Reconstruction of jaw (non-vascularised reconstruction) | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5910 | Needle biopsy of lung | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5200 | Epidural injection (cervical) | Intermediate | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5780 | Excision arthroplasty of first metatarso-phalangeal joint, (e.g. Keller, Bonney-Kessel procedures) including cheilectomy - bilateral | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 | Abdominal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1960 | Open infrarenal abdominal aortic aneurysm bifurcation graft | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0610 | Biopsy of lesion of orbit | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6700 | Pericardiectomy | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1310 | Percutaneous fine needle biopsy of lesion of kidney | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1913 | Pinning for bilateral slipped upper femoral epiphysis | Xmajor | £700.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5900 | Anastomosis of pancreatic duct (to another viscus) | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L3320 | Clipping of cerebral artery aneurysm | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2710 | Total gastrectomy and excision of surrounding tissue | Complex | £1,600.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4050 | Graft of skin or mucosa to mouth | Intermediate | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0220 | Total oesophagectomy and interposition of intestine | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6820 | Pericardiocentesis | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0400 | Biopsy of lesion of tissue of brain (including via a burr hole or stealth guided) | Complex | £900.00 | £610.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6723 | Tendo Achilles lengthening repeat procedure | Major | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7410 | Creation of arteriovenous shunt (synthetic graft) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1500 | Repair of rupture of diaphragm | complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8830 | Diagnostic arthroscopic examination of wrist joint, with or without biopsy (as sole procedure) | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9610 | Excision of cystic hygroma | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1240 | Insertion of tube drain into pleural cavity | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0410 | Wide excision of sweat glands -including bilateral axillae | Intermediate | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2400 | Transthoracic fundoplication and gastroplasty | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2920 | Insertion of canalicular or punctal plugs | Minor | £100.00 | £97.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2540 | Posterior excision of disc prolapse (including microdiscectomy +/- decompression) - lumbar region (1 or 2 levels) | Xmajor | £900.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6730 | Drainage of prostatic abscess | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 5.6 | Throat | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2320 | Open operation(s) on pharyngeal pouch | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0630 | Decompression of orbit | Major | £800.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5040 | Replacement of elbow and shoulder (single operation) | Complex | £1,600.00 | £883.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1702 | Microwave endometrial ablation including hysteroscopy | Major | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5960 | Femoro-distal calf bypass using vein | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8.10 | Great Vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2190 | Replacement of graft of thoraco-abdominal aneurysm | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J6180 | Drainage of pancreatic abscess | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7560 | VATS sympathectomy - unilateral | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4450 | Excision of sublingual gland | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2720 | Laparoscopic repair of incisional hernia requiring mesh | Intermediate | £470.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3880 | Stab cystostomy | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| R2810 | Curettage of delivered uterus | Minor | £250.00 | £181.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0250 | Nephrectomy - unilateral | Major | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0640 | Removal of foreign body from orbit | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7360 | Simple urethroplasty, eg primary repair, segment, anterior urethra (including cystoscopy) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3200 | Open reduction and internal fixation of cancellous bone graft scaphoid non-union | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3362 | Primary posterior fusion with instrumentation +/- decompression +/- discectomy (including Graf stabilisation and all fusion approaches) (lumbar region) including spinal cord monitoring | Complex | £1,500.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5280 | Map guided surgery for ventricular arrhythmias (including mapping) | Xmajor | £1,000.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0750 | Laparoscopically assisted right hemicolectomy | Xmajor | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6100 | Open excision of prostatatic adenoma | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0462 | Complex procedure to mid foot or hind foot with autogenous bone graft (osteotomy/fusion +/- tendon transfers/fixation) | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2100 | Repair of recurrent inguinal hernia | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.1 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L3730 | Endarterectomy and patch repair of subclavian artery | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4410 | Revision bypass for coronary artery(ies) (including harvesting of grafts) | Complex | £2,000.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.12 | General | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C8654 | Insertion of radioactive plaque into eye (including later removal) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4430 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with dilatation | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5230 | Epidurogram +/- epidural injection | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L0110 | Correction of truncus arteriosus | Complex | £1,300.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1510 | Myringotomy and insertion of tube through tympanic membrane (and bilateral) | Intermediate | £140.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0180 | Surgery for craniostenosis (more than one suture) | Xmajor | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J6200 | Incision of pancreas | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0282 | Total excision of trapezium | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0923 | Laser destruction of lesion(s) of skin - over 25cm² in area | Minor | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8620 | Ultrasound-guided foam Sclerotherapy for varicose vein(s) unilateral | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0310 | Submucous resection of nasal septum | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0380 | Stereotactic radiotherapy (SRT) using GammaKnife or similar SRT technology | Complex | £1,800.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5430 | Pulmonary lobectomy including segmental resection | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5180 | Diagnostic bronchoscopy +/- biopsy | Minor | £320.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4420 | Complex total replacement of ankle (ie including custom prosthesis, wedges, internal fixation of fractures) | Complex | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0820 | Open reduction and fixation of fractured jaw | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V5230 | Discogram/diagnostic vertebral disc injection under X-ray control | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6202 | Partial fusion of wrist | Intermediate | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2610 | Total amputation of penis | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4991 | Therapeutic Panendoscopy +/- excision biopsy, excision or destruction of lesions | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0400 | Open excision of lesion of oesophagus | Major | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6120 | Trabecular stent bypass microsurgery for open-angle glaucoma (including topical or local anaesthetic) | Major | £500.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0510 | Open pyeloplasty | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5630 | Secondary repair of acromioclavicular or sternoclavicular joint +/– internal fixation | Xmajor | £750.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1910 | Elective repair of aneurysm of ascending aorta | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4410 | Litholapaxy (including cystoscopy) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2010 | Primary repair of inguinal hernia ? bilateral | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1800 | Thymectomy for myasthenia gravis/thymoma | Major | £600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0850 | Isthmectomy of thyroid gland | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1250 | Creation of subcutaneous cerebrospinal fluid reservoir | Major | £560.00 | £311.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2290 | Excision of infected aortic graft with bypass | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2500 | Open repair of incisional hernia not requiring mesh | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5591 | VATS bullectomy - bilateral | Complex | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6110 | Excision of lesion of peripheral nerve (eg neurilemoma) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1660 | Tibial osteotomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4183 | Debridement and primary suture of wound with involvement of deeper tissue - Trunk and Limbs | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5180 | Corneal scraping for culture | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7580 | Open surgical stabilisation of patella, including soft tissue/tendon transfer or release, +/- application of cast (adult) | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W7490 | Reconstruction of posterior lateral corner of knee | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7010 | Implantation of neurostimulator into peripheral nerve | Major | £550.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3030 | Removal of external fixation from bone | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8110 | Creation of peritoneovenous shunt (Levine/Denver) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L0710 | Creation of shunt from subclavian artery to pulmonary artery | Complex | £1,300.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0383 | Lateral petrosectomy (for tumour) | Complex | £1,350.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3716 | Minimally invasive hip replacement (2 incisions) | Xmajor | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2730 | Colposcopy (+/- biopsy, polypectomy or vulvoscopy) | £100.00 | £129.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0860 | Partial thyroidectomy (not elsewhere classified) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 | Investigations | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20110 | ECG (Including reporting) | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5520 | Revisional prosthetic replacement of elbow | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4050 | Suture of conjunctiva | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J1300 | Percutaneous biopsy of lesion of liver | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2200 | Operation(s) on seminal vesicle | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4810 | Open biopsy of lesion of salivary gland | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6230 | Vascular implantation to carpal bone | Xmajor | £700.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L6000 | Endarterectomy of femoral artery | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR380 | Embolisation of aneurysm | Complex | £1,100.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0813 | Percutaneous biopsy of renal transplant | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8180 | Arthrotomy of small joint, including removal of loose body from joint | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W8782 | Flexible arthroscopy, +/- biopsy (as sole procedure) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2120 | Reduction of dislocation of temporomandibular joint | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H2220 | Endoscopic ultrasound for tumour staging, including diagnostic endoscopy | Intermediate | £450.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4100 | Drainage of conjunctival cyst | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2222 | Adrenalectomy - bilateral (open) | Xmajor | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| J5800 | Excision of lesion of pancreas | Major | £550.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A3000 | Repair of cranial nerve (intracranial) | Complex | £800.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5922 | Femoro-popliteal bypass using prosthesis | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8510 | Radical dissection of cervical lymph nodes | Complex | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G6080 | Laparoscopically assisted resection of small intestine | Major | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2600 | Percutaneous transluminal balloon operations on aorta | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7200 | Urethrectomy | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F5610 | Manipulative removal of calculus from parotid duct | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2953 | Excision of acoustic neuroma (vestibular schwannoma) - tumours more than 2.5cm or compressing brain stem (performed by single surgeon) | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0640 | Closure of bypass of oesophagus | Major | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1800 | Hysteroscopy (including biopsy, dilatation, curettage and resection of polyp(s) +/- Mirena coil insertion) | Intermediate | £210.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5900 | Excision of ganglion | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR140 | Unilateral stereotactic core biopsy breast | Intermediate | £320.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8194 | Arthroscopic sub-acromial decompression and excision of distal clavicle (including arthroscopic procedures in glenohumeral joint) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4100 | Bypass for coronary artery(ies) including harvesting of grafts and endarterectomy | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0212 | Excision of lesion of orbit - anterior approach | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0300 | Open partial nephrectomy | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6712 | Prostatic cryotherapy | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0310 | Reconstruction of external ear for anotia/microtia using cartilage | Complex | £1,350.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0222 | Nephroureterectomy for live donor transplantation | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4480 | Removal of foreign body in deeper tissue | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3364 | Laparoscopic anterior resection - high (i.e. colorectal anastomosis above the peritoneal reflection) | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2700 | Subcutaneous mastectomy with immediate implant | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2810 | Partial gastrectomy and excision of surrounding tissue | Complex | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.8 | Major vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7040 | Open cannulation of intra abdominal artery for infusion chemotherapy | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4690 | Implantation of synthetic corneal rings for keratoconus (including INTACS) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2590 | Revision of anti-reflux procedures | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2030 | Arthroplasty of temporomandibular bone joint | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4440 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with insertion of percutaneous endoscopic gastrostomy/percutaneous endoscopic jejunostomy | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3594 | Plastic procedures on nipple | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR280 | Insertion of aortic metallic stent-graft | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7982 | Arthroscopic sub acromial decompression and rotator cuff repair (including arthroscopic procedures in glenohumeral joint) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8280 | Arthroscopic meniscectomy (including debridement) – bilateral | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0604 | Secondary excision of malignant lesion - head and neck | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 18 | Chemotherapy | |||||||||||||||||||||||||||||||||||||||||||||||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
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| 18.0. | Chemotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0002 | Clinical supervision and planning for delivery of chemotherapy And/Or Systemic Anti-Cancer Therapy For 1-14 Days | £250.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0702 | Excision of ectopic bone around a total hip replacement | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0620 | Drainage of orbit | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4680 | Repair of faecal fistula | Intermediate | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1742 | Lateral rhinotomy into sinuses | Intermediate | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0840 | Exploration of renal transplant for bleeding | Intermediate | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6200 | Total fusion of all joints of wrist with or without graft and with or without internal fixation | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0822 | Amputation of whole ray | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 | Abdominal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L4600 | Other open operations on other visceral branch of abdominal aorta | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4180 | Full or partial thickness rectal biopsy | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q2080 | Ventrosuspension of uterus (including laparoscopic) | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3040 | Application of Ilizarov frame for secondary non-union/mal-union including osteotomy | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2520 | Repair of urethrovaginal fistula (including cystoscopy) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0110 | Total excision of nose | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4182 | Debridement and primary suture of wound with involvement of deeper tissue - Head and Neck | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5550 | Excision of radial head (as sole procedure) | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8582 | Operations for recurrent varicose veins without re-exploration of groin or popliteal fossa - bilateral | Xmajor | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6830 | Secondary or second repair of 1st stage reconstruction of flexor of hand | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7300 | Radiofrequency (including pulsed denervation), cryoprobe or phenol for permanent lesion of named peripheral nerve +/- image guidance | Intermediate | £200.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3810 | Injection into larynx | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6940 | Irrigation/aspiration of anterior chamber | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6530 | Endoscopic resection of prostate (TUR) (including cystoscopy) | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1440 | Irrigation of cerebroventricular shunt | Minor | £160.00 | £233.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5280 | Revision retropubic suspension of neck of bladder (including colposuspension and cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1530 | Myringotomy (and bilateral) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7590 | Insertion of suburethral tape sling (e.g. TOT or TVT) +/- administration of local anaesthetic by operating surgeon (including cystoscopy) | Major | £370.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5700 | Thoractomy lung volume reduction - bilateral | Complex | £1,300.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2930 | Removal of skeletal traction from bone | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7510 | Secondary insertion of lens implant | Major | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.3 | Trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4030 | Tracheoplasty | Major | £1,000.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0940 | Photodynamic therapy (PDT) to non malignant lesions of skin | Intermediate | £250.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2402 | Transthoracic fundoplication | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4400 | Partial excision of spinal cord | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4760 | Fine needle aspiration cytology | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6702 | Secondary open reduction of dislocation of small joint | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Y3800 | Insertion of indwelling axillary catheter | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0900 | Excision of left hemicolon | Xmajor | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1800 | Drainage/debridement of bone(s), including sequestectomy for osteomyelitis | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8580 | Operations for recurrent varicose veins with re-exploration of groin and/or popliteal fossa - bilateral | Xmajor | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3900 | Partial excision of trachea with reconstruction | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5310 | Total prosthetic replacement of wrist joint | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3592 | Micropigmentation (tattooing) of nipple areola complex | Minor | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0820 | Curettage/cryotherapy of lesions of skin including cauterisation - four or more | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5240 | Banding of haemorrhoids | £75.00 | £71.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8780 | Ligation/stripping of long and short saphenous veins (including local excision/multiple phlebectomy) bilateral | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7302 | Continuous nerve block +/- image guidance (as sole procedure) | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F3480 | Adenotonsillectomy (and bilateral) | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0655 | Removal of benign lesion on head and neck requiring flap closure (excluding advancement flap) (excluding lipoma) | Intermediate | £210.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G6710 | Intubation of jejunum for decompression of intestine (without laparotomy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2781 | Laparoscopic vagotomy/seromyotomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.9 | Abdominal wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7972 | Exploration and repair of groin disruption including repair of muscle fascia and tendons (Gilmore's Groin Repair) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2650 | Probing of nasolacrimal system with/without syringing and/or irrigation | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6520 | Tendon sheath injection of therapeutic substance including viscosupplement +/- image guidance | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR303 | Additional management of brain arteriovenous malformation (per additional intervention) | Minor | £1,900.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22011 | Recording and reporting on evoked potential study | Minor | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2742 | Modified radical mastectomy including lymph node sampling | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5730 | Surgical toilet and debridement of deep wound, including traumatic or post-operative aetiology | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4500 | Open operations on spinal cord | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3920 | Cauterisation including cryotherapy to conjunctival lesion | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2730 | Highly selective vagotomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0712 | Radical trachelectomy including laparoscopic and removal of lymph nodes +/- ureterolysis | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4920 | Conversion of hemiarthroplasty to total shoulder replacement | Complex | £800.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2340 | Repair of enterocele (+/- posterior repair colporrhaphy) (as sole procedure) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5050 | Reverse polarity arthroplasty of shoulder | Xmajor | £900.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| R1820 | Caesarean delivery | Major | £600.00 | £461.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5250 | Needle suspension of bladder neck (including cystoscopy) | Intermediate | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7042 | Cannulation or decannulation for ECMO (Extracorporeal membrane oxygenation) | Major | £650.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1160 | Canthotomy | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0382 | Total petrosectomy (for tumour) | Complex | £1,350.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.11 | Retina | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5432 | Conventional retinal surgery (may include scleral buckling, injection of gas, drainage and retinopexy) | Xmajor | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4140 | Removal of posterior spinal implant | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N3210 | Biopsy of lesion of penis | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6600 | Release of entrapment of deeply placed peripheral nerve | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7850 | Open arthrolysis of elbow | Major | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4130 | Perianal excision of lesion of rectum (including sigmoidoscopy) | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3016 | Mastectomy and immediate reconstruction of breast using fat transfer | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L6800 | Repair of limb artery | Xmajor | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2970 | Sub-total laryngectomy | Complex | £1,350.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1380 | Arthroscopic femoro-acetabular surgery for hip impingement syndrome | Xmajor | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1150 | Graft of skin to canthus | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7492 | Open/arthroscopic lateral release | Intermediate | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25110 | Coeliac plexus block, splanchnic nerve block, hypogastric block - therapeutic +/- Image Guidance | Intermediate | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0800 | Excision of transverse colon | Xmajor | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1040 | Simple mastoidectomy | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J6300 | Open examination of pancreas | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8610 | Biopsy/sampling of cervical lymph nodes | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0900 | Operations on aberrant thyroid tissue (including excision/removal of retrosternal goitre) | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4722 | Thoracotomy and closure of broncho-pleural fistula | Xmajor | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J6100 | Open drainage of lesion of pancreas | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR950 | Occlusion of fistula under imaging control | Major | £700.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6402 | Tendon transfer of hand – single | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7340 | Exploration and grafting of brachial plexus | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8193 | Arthroscopic subacromial decompression | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2810 | Excision/destruction of lesion of palate | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6000 | Repeat excision of ganglion | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1800 | Placement of valve to cardiac conduit | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2830 | Resuture of previous incision in abdominal wall (“burst abdomen”) | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7340 | Exploration and grafting of brachial plexus | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4902 | Shoulder hemiarthroplasty with reconstruction for fracture | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6770 | Peroneal sling/groove reconstruction and replacement of dislocated peroneal tendons | Major | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1750 | Transnasal repair of leaking CSF (Including endoscopic) | Xmajor | £1,000.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR510 | Fluoroscopically guided discectomy (including laser) | Major | £650.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2986 | Reconstruction of breast using deep inferior epigastric perforator flap (DIEP) (including delayed reconstruction) - unilateral (Single Flap) | Complex | £2,750.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7312 | Repair of penile/perineal hypospadias | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E6100 | Open resection of invasive mediastinal tumour | Complex | £1,200.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.1 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2950 | Carotid endarterectomy | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S3623 | Full thickness graft, trunk and limbs – each additional 25cm2 in area | Minor | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5704 | Thoracotomy bullectomy - unilateral +/- pleurodesis in presence of emphysema | Xmajor | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0230 | Septorhinoplasty including graft/implant following trauma or excision of tumour (including attention to turbinates) | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1480 | Insertion of pleuro-peritoneal shunt | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3640 | Repair of bladder exstrophy | Complex | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0512 | Simple reconstruction of socket (not including implant or graft) | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3800 | Open operations on stomach not elsewhere classified | Major | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5000 | Percutaneous examination of bile duct | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3020 | Adjustments to Ilizarov frame/rings | Major | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6410 | Repair of prolapsed iris | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR120 | CT/MRI guided biopsy(ies) | Intermediate | £320.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4400 | Excision of parotid gland (other than F4410/F4430) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8640 | Sampling of internal mammary lymph nodes | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0800 | Vaginal hysterectomy without laparoscopic assisted | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4680 | Endoscopic mucosal resection (upper gastrointestinal tract) (EMR) | Intermediate | £300.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR936 | Insertion of guidewire and/or marker into breast lesion under imaging control | Minor | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0302 | Laparoscopic partial nephrectomy | Major | £650.00 | £402.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4142 | Removal of posterior scoliosis instrumentation (as sole procedure) | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6780 | Primary repair of Achilles tendon | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0740 | Open hepatectomy and ablation | Complex | £1,900.00 | £1,357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0630 | Patellectomy | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0220 | Total oesophagectomy and interposition of intestine | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1820 | Excision of segment of ureter | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6822 | Delayed or secondary repair of Achilles tendon with tendon or fascial graft | Xmajor | £650.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.10 | Vitreous | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7910 | Anterior vitrectomy | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8603 | Therapeutic arthroscopy of shoulder (as sole procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.10 | Gastrointestinal | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR585 | Percutaneous gastrostomy | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| XR590 | Percutaneous gastrojejunostomy | Major | £600.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20130 | Exercise ECG (including base line 12 lead ECG and reporting) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Incision/excision |
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| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 | Investigations | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20141 | Continuous ambulatory ECG for up to 72 hours (including reporting) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1.4 | Consultations and Physicians’ fees | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
In-patient care fees are only claimable by the person in primary charge of the case.... Other specialists may claim for specific consultations for specific purposes. ITU fees are expected to include insertion of central lines, arterial lines, dialysis lines, pulmonary artery catheters and similar.
|
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| 1.5 | Practitioner and Therapist fees | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
We will pay fees up to the contracted or agreed rate which we have in-place with the individual recognised practitioner who provides the treatment. The member will not be responsible for any shortfall (subject to any policy or benefit limitations).
The following fees are reimbursable per session of treatment. No more than one session can be claimed on the same day.
Neuropsychological and Neuropsychiatric Assessment We will pay a fee of up to £600 for an eligible assessment. To qualify, the assessment must be pre authorised by our customer service department. If not pre authorised, the reimbursement limit of £100 for psychologists and £250 for psychiatrists will apply, and we will shortfall the claim. The payment we make is to include all preparation, report writing, travel and any other administrative costs. |
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| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
We will provide benefit for surgeon and anaesthetist standby during coronary angioplasty provided the surgeon and anaesthetist are physically present and have no other obligations at that time. There is a code AA588 for this purpose. Please note, however, should surgery become necessary we will not also reimburse a charge for standby. The benefit for therapeutic interventional procedures such as angioplasty with stenting or ablation includes an amount for any diagnostic procedure performed on the same day. Transoesophageal echocardiography should not be charged as an addition with valve procedures. We will not pay additional amounts for supervision of post-operative care by cardiologists. In exceptional circumstances we will consider charges but these must be justified and agreed with us before they are invoiced. We acknowledge that the procedure K3580 - Trans catheter aortic valve implantation (TAVI) requires a multidisciplinary approach from a cardiologist and a cardio-thoracic surgeon. The fee we publish for K3580 is payable to the team so invoices may either be submitted by one specialist for the full amount or by both specialists for 50% of the published fee. The fee of £2300 is not claimable by both specialists. |
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| 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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| 4.10 | Vitreous | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7924 | Intravitreal injection of pharmaceutical for central retinal vein occlusion | Minor | £350.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Cervical region |
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| V2282 | Prosthetic intervertebral disc replacement - cervical region (1 or 2 levels) +/- Spinal Cord Monitoring | Complex | £1,300.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2300 | Revisional posterior decompression +/– foraminotomy (cervical region) | Complex | £1,300.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2990 | Open door laminoplasty of the cervical region (Hirobyashi) | Complex | £1,200.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V3720 | Posterior fusion +/- instrumentation - cervical region (1 or 2 levels) Including Spinal Cord Monitoring | Xmajor | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2900 | Anterior discectomy - cervical region (1 or 2 levels) | Xmajor | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2902 | Revisional anterior discectomy (cervical region) | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2950 | Anterior discectomy, decompression and fusion (including bone grafting) - cervical region (1 or 2 levels) | Complex | £1,200.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2980 | Combined anterior and posterior fusion of cervical spine | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V3730 | Trans oral surgery including posterior fixation | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
|
Thoracic region |
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| V2402 | Posterior decompression (thoracic region) Including Spinal Cord Monitoring | Xmajor | £1,200.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2400 | Posterior decompression with fusion (thoracic region) Including Spinal Cord Monitoring | Complex | £1,200.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
|
Lumbar region |
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|
Scoliosis (including kyphosis, fractures, tumours and infections) |
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| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Flaps Unless explicitly stated these codes relate to the formation, division and transfer of the flap and include repair of the donor site. They do not include excision of skin or wound at the recipient site. |
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|
Free Skin Grafts Unless explicitly stated these codes relate to the formation, division and transfer of the graft and include repair of the donor site. They do not include excision of skin or wound at the recipient site. All definitions relate to recipient sites unless otherwise stated. |
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| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Long bones |
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|
Small bones |
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|
Pelvis/acetabulum and femur |
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|
Joints |
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|
Fixation devices |
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|
Other (eg POP) |
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| 16.6 | Hand | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Repair/reconstruction |
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|
Fixation/arthrodesis |
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|
Other (eg amputation) |
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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Incision/excision |
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|
Repair/reconstruction |
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|
Fixation/arthrodesis |
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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Incision/excision |
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|
Repair/reconstruction |
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| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Incision/excision |
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|
Repair, reconstruction and replacement |
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|
Fixation/arthrodesis |
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|
Other |
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| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Incision/excision |
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|
Repair/reconstruction |
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|
Fixation/arthrodesis |
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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
Ankle |
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|
Hind foot and mid foot |
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|
Forefoot |
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|
Hallux |
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|
Toes |
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|
General foot |
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| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2842 | Frenuloplasty of penis | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4840 | Dilatation of tracheal stricture including insertion of stent | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5410 | Dupuytren’s subcutaneous fasciotomy Minor | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H6260 | Proctoscopy (+/- Biopsy) | Minor | £50.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6530 | Carpal tunnel release (endoscopic) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6530 | Carpal tunnel release (endoscopic) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6570 | Carpal tunnel release (endoscopic) - Bilateral | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6570 | Carpal tunnel release (endoscopic) - Bilateral | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6740 | Cubital tunnel release (endoscopic) (without transposition) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6740 | Cubital tunnel release (endoscopic) (without transposition) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6750 | Cubital tunnel release (endoscopic) Bilateral (without transposition) | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6750 | Cubital tunnel release (endoscopic) Bilateral (without transposition) | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0633 | Prosthetic replacement of Patellofemoral joint - bilateral (as sole procedure) | Xmajor | £1,100.00 | £454.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0890 | Vaginal hysterectomy including salpingo-oophorectomy (including laparoscopically assisted) +/- ureterolysis | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6982 | Tenolysis of flexor tendon of hand | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4280 | Correction of adult degenerative or adult scoliosis including decompression +/- fusion (including spinal cord monitoring) | Complex | £2,000.00 | £1,169.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4900 | Repair of spinal myelomeningocele | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4230 | Revision of total replacement of knee joint | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0420 | Reconstruction of lip using skin flap | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0330 | Fusion of first metatarso-phalangeal joint | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1240 | Exploration of facial nerve, mastoid segment, facial nerve | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6581 | Coronary angioplasty following angiography with fractional flow study on the same day, +/- insertion of stent | Complex | £1,300.00 | £779.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K5020 | Coronary angiography proceeding to angioplasty on the same day, +/- insertion of stent | Complex | £1,100.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K6590 | Coronary angiography including intravascular ultrasound | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K5050 | Coronary angioplasty following angiography with intravascular ultrasound on the same day, +/- insertion of stent | Complex | £1,150.00 | £779.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L3400 | Open operations on cerebral artery | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2822 | Examination of ear under general anaesthetic (as sole procedure) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7440 | Allograft anterior cruciate ligament reconstruction | Xmajor | £750.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0303 | Robotic assisted laparoscopic partial nephrectomy | Major | £650.00 | £402.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3380 | Prosthetic intervertebral disc replacement - lumbar region (1 or 2 levels) | Complex | £1,300.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E6110 | Open excision of mediastinal tumour including congenital cysts/posterior chest wall lesions | Xmajor | £650.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X4810 | Change of cast without general anaesthetic (as sole procedure) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.7 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR315 | Endoluminal stone extraction from salivary duct under imaging control | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2010 | Adenoidectomy | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0510 | Total excision of colon and ileorectal anastomosis | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5790 | Sacroiliac joint injection under image guidance (and bilateral) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6105 | Insertion of dual chamber implantable cardioverter defibrillator (ICD) | Complex | £1,250.00 | £454.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2780 | Vagotomy and pyloroplasty | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4640 | Fine needle aspiration of parotid gland | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0730 | Repair of congenital oesophageal atresia (with or without fistula) | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2620 | Manipulation under anaesthesia of fractured nose (as sole procedure) | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3100 | Reconstruction of larynx with graft | Complex | £1,350.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4010 | Posterior correction of idiopathic juvenile kyphosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | £2,500.00 | £1,299.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V4122 | Anterior correction of idiopathic juvenile kyphosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | £2,500.00 | £1,299.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V4160 | Posterior correction of degenerative adult kyphosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V4150 | Anterior correction of degenerative adult kyphosis with instrumentation, +/- fusion (including spinal cord monitoring) | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6180 | Excision of lesion of major nerve | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2916 | Mastectomy and immediate reconstruction of breast using extended latissimus dorsi flap | Xmajor | £1,650.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3681 | Stroboscopy of larynx | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2831 | Re-excision of lesion of breast if resection margins are not clear with local mobilisation | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3651 | Diagnostic aspiration of bone marrow | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W3652 | Trephine biopsy of bone marrow | Minor | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 18 | Chemotherapy | |||||||||||||||||||||||||||||||||||||||||||||||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
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| 18.0. | Chemotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5480 | Intrathecal chemotherapy | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4950 | Fat transfer, including extraction and volume adjustment, of scar defect following trauma (excluding breast) | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6060 | Lead replacement for Pacemaker or implantable cardioverter defibrillator (ICD) | Major | £650.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K6513 | Adult cardiac catheterisation - radial access (including coronary arteriography/ catheterisation of right/left side of heart/contrast radiology) | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K6511 | Adult cardiac catheterisation - femoral access (including coronary arteriography/ catheterisation of right/left side of heart/contrast radiology) | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K6115 | Insertion of an implantable cardioverter defibrillator with subcutaneous leads (subcutaneous ICD) | Complex | £1,250.00 | £454.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q2081 | Myolysis of uterine fibroids | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.10 | Vitreous | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7940 | Intravitreal injection of pharmaceutical agent (not elsewhere classified) | Minor | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0900 | Diagnostic laparoscopy (including any biopsy) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4713 | Bladder instillation as sole procedure | Minor | £100.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6111 | Insertion of combined biventricular pacemaker and cardioverter defibrillator (CRT-D) | Complex | £1,250.00 | £454.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3490 | Endoscopic removal of percutaneous endoscopic gastrostomy (PEG) tube | Intermediate | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4714 | Therapeutic injection into bladder wall (including cystoscopy) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9282 | Joint fluid examination (eg polarising microscopy) performed by consultant including aspiration of fluid | £75.00 | £129.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3180 | Thyroplasty (Isshiki type 1) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G1470 | Fibreoptic endoscopic photodynamic therapy (PDT) of lesion of oesophagus | Intermediate | £400.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.8 | Heart – cardiac surgery | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2720 | Endovascular aneurysm repair (EVAR) of suprarenal aorta, with insertion of fenestrated graft (up to two orifices) | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| L2780 | Endovascular aneurysm repair (EVAR) of suprarenal aorta, with insertion of fenestrated graft (three to four orifices) | Complex | £1,500.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| L2710 | Endovascular aneurysm repair (EVAR) of infrarenal aorta | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3345 | Mobilisation of the lumbar/thoracic vessels to provide spinal surgical access (by vascular surgeon) as sole procedure | Major | £650.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9030 | Intraoperative sentinel node mapping, using One Step Nucleic Acid Amplification (OSNA), for breast cancer | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9030 | Intraoperative sentinel node mapping, using One Step Nucleic Acid Amplification (OSNA), for breast cancer | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6514 | Adult cardiac catheterisation - brachial access (including coronary arteriography/ catheterisation of right/left side of heart/contrast radiology) | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7030 | Limited/single core transrectal needle biopsy of prostate +/- ultrasound guidance | Minor | £150.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0710 | Radical hysterectomy and lymphadenectomy (Wertheim's) +/- ureterolysis | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S1900 | Distant pedicle flap – elevation including transfer (including closure/grafting to secondary defect) | Complex | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1470 | Median drainage of frontal sinus (modified Lothrop procedure) and bilateral | Complex | £2,000.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4032 | Tracheoplasty for congenital conditions | Complex | £1,000.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0830 | Vaginal hysterectomy with laparoscopic assistance +/- ureterolysis | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5720 | Ablation of AV nodal re-entry tachycardia (including mapping) | Complex | £1,100.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4690 | Endoscopic submucosal dissection of gastric lesions | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.3 | Duodenum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G5050 | Endoscopic submucosal dissection of duodenal lesions | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0951 | Radical clearance of sarcoma of head and neck necessitating flap reconstruction | Complex | £1,000.00 | £649.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0951 | Radical clearance of sarcoma of head and neck necessitating flap reconstruction | Complex | £1,000.00 | £649.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9050 | Shoulder hydrodistension +/- image guidance | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8542 | Radiofrequency ablation of single venous trunk +/- phlebectomies - unilateral | Intermediate | £400.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2120 | High resolution oesophageal manometry | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5770 | Ablation of arrhythmia in complex congenital heart disease (including mapping) | Complex | £1,400.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K5790 | Ablation of left atrial tachycardia (including mapping) | Complex | £1,350.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K6050 | Replacement implantable cardioverter defibrillator (ICD), without lead change | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8543 | Radiofrequency ablation of single venous trunk +/- phlebectomies - bilateral | Major | £600.00 | £389.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0780 | Radiofrequency thermocoagulation of liver with scalpel liver resection | Complex | £1,100.00 | £779.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0390 | Foramen magnum decompression | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0656 | Removal of lipoma | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X3520 | IV sedation administered by anaesthetist (as sole procedure) | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5760 | Ablation of atrial fibrillation by isolation of the pulmonary veins (including mapping) | Complex | £1,450.00 | £584.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2620 | Repair of recurrent incisional hernia requiring mesh | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2640 | Repair of recurrent incisional hernia requiring removal of previously inserted mesh | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2780 | Component Separation Technique (CST) repair of recurrent incisional abdominal hernia +/- mesh | Xmajor | £1,500.00 | £779.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4920 | Percutaneous transluminal angioplasty of coronary artery(ies) for chronic total occlusions (CTO), +/- insertion of stent | Complex | £1,500.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| K5110 | Angioscopy | Intermediate | £400.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1350 | Antegrade pyelogram (including bilateral) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5100 | Endobronchial ultrasound (as sole procedure) | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J1041 | Hepatic venous wedge pressure (HVWP) | Intermediate | £300.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £1,000.00 | £649.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £1,000.00 | £649.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0514 | Prosthetic surface arthroplasty of interphalanageal/metacarpo-phalangeal joint – single joint (both cemented and uncemented) | Major | £600.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £210.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3721 | Posterior fusion +/- instrumentation - cervical region (3 or more levels) Including Spinal Cord Monitoring | Xmajor | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2901 | Anterior discectomy - cervical region (3 or more levels) | Xmajor | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2201 | Posterior decompression +/- foraminotomy - cervical region (3 or more levels) | Complex | £1,200.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V3381 | Prosthetic intervertebral disc replacement - lumbar region (3 or more levels) | Complex | £1,300.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V3341 | Primary anterior discectomy, decompression and anterior fusion +/- instrumentation - lumbar region (3 or more levels) including spinal cord monitoring | Xmajor | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2501 | Primary posterior fusion +/- decompression +/- discectomy - lumbar region (3 or more levels) including spinal cord monitoring | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4370 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with elective banding of oesophageal varices | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| G4371 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with therapy for acutely bleeding ulcer or varices | Minor | £250.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2283 | Prosthetic intervertebral disc replacement - cervical region (3 or more levels) +/- spinal cord monitoring | Complex | £1,300.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2951 | Anterior discectomy, decompression and fusion (including bone grafting) - cervical region (3 or more levels) | Complex | £1,200.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2546 | Posterior excision of disc prolapse with undercutting facetectomy +/- decompression - lumbar region (3 or more levels) | Xmajor | £900.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2541 | Posterior excision of disc prolapse (including microdiscectomy +/- decompression) - lumbar region (3 or more levels) | Xmajor | £900.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7900 | Excision of medial eminence 1st or 5th MT head with soft tissue repair (bunionectomy) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2930 | Biopsy of lesion of vagina | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 14.5 | Vulva/labia | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P0910 | Biopsy of lesion of vulva | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0102 | Transplantation of kidney - 1st and 2nd transplant | Xmajor | £900.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR391 | Embolisation of arteriovenous malformation (AVM) e.g. of foot, minor organ | Major | £550.00 | £291.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2120 | Total removal of vaginal mesh/tape with reconstruction of vagina and/or uretha, including cysoscopy and/or proctoscopy [fees on application] | Complex | £1,000.00 | £389.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| P2110 | Partial removal of vaginal mesh/tape with reconstruction of vagina and or/uretha, including cystoscopy and/or proctoscopy [fees on application] | Complex | £1,000.00 | £389.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0960 | Excision of benign tumour of bone with bone grafting | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0422 | Triple fusion of joints of hindfoot with autogenous graft | Major | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7511 | Excision of arteriovenous malformation from peripheral vessel | Intermediate | £250.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1818 | Reverse ptosis repair of eyelid | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2996 | Reconstruction of breast using deep inferior epigastric perforator flap (DIEP) (including delayed reconstruction) - bilateral (single flap per breast) | Complex | £4,125.00 | £2,143.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR160 | Percutaneous image guided fine needle aspiration(s) (FNA) - Unilateral | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7341 | Yag laser photodisruption of posterior capsule of lens (including laser capsulotomy) - bilateral | Intermediate | £300.00 | £311.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3210 | Gastro–jejunostomy | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3111 | Holmium Laser Lithotripsy for calculi of ureter (including cystoscopy and insertion/removal of stent) | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6015 | Ankle arthrodesis – open | Intermediate | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5260 | Low voltage treatment of internal haemorrhoids | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0961 | Radical clearance of benign bone tumour with reconstruction +/- insertion of prosthesis | Complex | £900.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.5 | Joints, including replacement/reconstruction (not listed elsewhere) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9032 | Injection of viscosupplement into joint with image guidance | Minor | £115.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W9033 | Injection of viscosupplement into joint with image guidance - bilateral | Minor | £135.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W9035 | Injection(s) +/- aspiration, into two or more joints, cysts, bursae with image guidance - bilateral | Minor | £135.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W9042 | Injection of viscosupplement into joint | Minor | £50.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W9043 | Injections of viscosupplement into joints - bilateral | Minor | £75.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W9045 | Injection(s) +/- aspiration, into two or more joints, cysts, bursae - bilateral | Minor | £115.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5211 | Epidural injection (caudal) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7761 | Repair of hip labral tear | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N3032 | Revision of circumcision | Intermediate | £220.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25160 | Trigeminal ganglion radiofrequency lesion (under X-ray control) | Intermediate | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT251 | Planning for insertion and removal of radioactive agent (brachytherapy) into rectal tumour | £360.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6170 | Goniosynechialysis or goniopuncture (with laser or operatively) (including topical or local anaesthetic) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7313 | Repair of penile shaft hypospadias | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT252 | Insertion and removal of radioactive agent (brachytherapy) into rectal tumour | £360.00 | £259.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5410 | Epidural blood patch | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT281 | Planning for insertion and removal of radioactive agent (brachytherapy) into the vagina | £360.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT282 | Insertion and removal of radioactive agent (brachytherapy) into the vagina | £360.00 | £259.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5750 | Laparoscopic distal pancreatectomy | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5830 | Endomyocardial biopsy | Intermediate | £400.00 | £343.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1101 | Correction of hydrocele(s) - bilateral | Intermediate | £375.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2070 | Transtympanic steroid injection (including topical or local anaesthetic) | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4610 | Minimally invasive direct coronary artery bypass (MIDCAB) including harvesting of graft | Complex | £2,300.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8780 | Sentinel node biopsy (except where otherwise listed) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 19 | Haematology (Hospital Use Only) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Haematology (Hospital Use Only) | ||||||||||||||||||||||||||||||||||||||||||||||||||
| 19.1 | Bone Marrow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
The CCSD codes below are solely for use by hospitals. We do not expect any specialist to bill for these services. The fees for these services should be confirmed with AXA Health in advance of treatment. |
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| 19.2 | Stem Cell | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
|
The CCSD codes below are solely for use by hospitals. We do not expect any specialist to bill for these services. The fees for these services should be confirmed with AXA Health in advance of treatment. |
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| 19.2 | Stem Cell | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| U0100 | Autologous peripheral blood stem cell transplant | £0.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6016 | Ankle arthrodesis with autogenous graft | Intermediate | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1320 | Fixation of testis | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6180 | Bleb needling +/- antimetabolites (including topical or local anaesthetic) | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 4.7 | Sclera | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6181 | Laser suture lysis (including topical or local anaesthetic) | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6990 | Insertion of valve into anterior chamber of eye | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2900 | Excision of lesion of cranial nerve (intracranial) | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2880 | Epley manoeuvre (code for specialist use only) | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7451 | 2 stage revision anterior cruciate ligament reconstruction - first stage | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W7452 | 2 stage revision anterior cruciate ligament reconstruction - second stage | Major | £750.00 | £454.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0521 | Microscopically controlled excision of lesion of skin or subcutaneous tissue (Mohs micrographic surgery) without reconstruction | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5790 | Repair to plantar plate | Major | £550.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0282 | Laparoscopic nephroureterectomy | Xmajor | £800.00 | £389.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1992 | Delayed repair of aortic dissection (ie more than two weeks after happening) | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2918 | Mastectomy and immediate reconstruction of breast using fixed prosthesis and acellular dermal matrix (ADM) - unilateral | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2501 | Open repair of incisional hernia requiring mesh | Intermediate | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2503 | Laparoscopic repair of incisional hernia not requiring mesh | Intermediate | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1120 | Diagnostic ureterorenoscopy (+/- cystoscopy) | Minor | £200.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| M1130 | Therapeutic ureterorenoscopy (+/- cystoscopy and insertion/removal of stent) | Minor | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2914 | Mastectomy followed by immediate Deep Inferior Epigastric Flap (DIEP) reconstruction - bilateral | Complex | £4,500.00 | £2,339.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6111 | Laser trabeculoplasty (including topical or local anaesthetic) - unilateral | Intermediate | £250.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.7 | Teeth | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0911 | Coronectomy | Intermediate | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5210 | Revision of unicompartmental knee replacement | Complex | £850.00 | £454.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W5800 | Conversion of a unicompartmental knee replacement to a total replacement of knee joint | Complex | £1,100.00 | £519.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT253 | Low energy contact X ray brachytherapy (the Papillon technique) for early stage rectal cancer | £200.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V6080 | Percutaneous disc decmpression using coblation | Major | £650.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7013 | Placement of tined lead neurostimulator not at time of permanent implant | Intermediate | £450.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.9 | Thorax | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR600 | Insertion of oesophageal metallic stent under imaging control | Major | £500.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8880 | Endovenous mechanochemical ablation for varicose veins - unilateral | Intermediate | £250.00 | £161.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7714 | Primary open or arthroscopic shoulder stabilisation pocedure (including labral/SLAP/tendon repair) | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2621 | Frenotomy /frenectomy of tongue under local anaesthetic | £150.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20144 | Continuous ambulatory ECG for over 72 hours and up to 7 days (including reporting) | £125.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9170 | Manipulation of foot/ankle joint under local anaesthetic +/- injection (as a sole procedure) | Minor | £110.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5924 | Femoro-popliteal bypass using vein cuff/patch | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5230 | Injection of sclerosing substance into haemorrhoids | £75.00 | £129.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0480 | Abdominal revision of restorative proctocolectomy | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2200 | Revision of prosthesis of abdominal aorta | Complex | £2,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0941 | Percutaneous nephrolithotomy (including cystoscopy and retrograde catheterisation) (involving two specialties) (we will pay this fee per specialty) | Complex | £700.00 | £493.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7525 | Repositioning of lens implant | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4512 | Examination of bladder using hexaminolevulinate blue-light fluorescence cystoscopy +/- resection of lesions | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4831 | Trial of neurostimulator to spinal cord (as sole procedure) not at time of permanent implant | Major | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2340 | Transabdominal repair of diaphragmatic hernia (excluding hiatus hernia) | Complex | £800.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3650 | Diagnostic aspiration and trephine biopsy of bone marrow, including analysis | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7315 | Secondary adjustment of penile skin following hypospadias repair | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 19 | Haematology (Hospital Use Only) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Haematology (Hospital Use Only) | ||||||||||||||||||||||||||||||||||||||||||||||||||
| 19.2 | Stem Cell | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2917 | Reconstruction of breast using fixed prosthesis and acellular dermal matrix (ADM) (including delayed reconstruction) | Major | £600.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0220 | Septorhinoplasty (including attention to turbinates) | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5040 | Rotoblation of coronary vessel(s) percutaneous transluminal rotational atherectomy (PCRS) +/- insertion of stent | Complex | £1,100.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3412 | Laparoscopic cystoprostatectomy (with construction of intestinal conduit or bladder) | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0312 | Microwave ablation for primary or metastatic cancer of the liver | Major | £825.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5540 | Laser resection of lung metastases | Complex | £1,000.00 | £649.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 | Investigations | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 64301 | Echocardiography including bubble contrast (including reporting) as sole procedure | £150.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6180 | Bleb needling +/- antimetabolites (including topical or local anaesthetic) | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| C6181 | Laser suture lysis (including topical or local anaesthetic) | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| E2880 | Epley manoeuvre (code for specialist use only) | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| F2621 | Frenotomy /frenectomy of tongue under local anaesthetic | £150.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P0610 | Laser destruction of lesion of vulva | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1280 | Ultrasound guided radiofrequency ablation of benign thyroid nodule | Intermediate | £250.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.11 | Liver | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR550 | Transarterial chemoembolization (TACE), +/- drug eluting bead (DEB) | Major | £600.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 18 | Chemotherapy | |||||||||||||||||||||||||||||||||||||||||||||||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
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| 18.0. | Chemotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0100 | Electrochemotherapy for malignant lesions | £400.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X0100 | Electrochemotherapy for malignant lesions | £400.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR110 | Ultrasound guided biopsy(ies) | Intermediate | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2180 | Ambulatory 24h pH and impedance monitoring | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2180 | Ambulatory 24h pH and impedance monitoring | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR362 | Embolisation of pelvic vein varices | Major | £500.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8881 | Endovenous mechanochemical ablation for varicose veins - bilateral | Intermediate | £375.00 | £246.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5920 | Fusion of first metatarso-phalangeal joint with bone grafting +/- internal fixation (as sole procedure) | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X3530 | Sedation or general anaesthesia for MRI or CT scan | £0.00 | £129.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G8083 | Therapeutic oesophago-gastro-duodenoscopy (OGD) and immediate colonoscopy includes forceps biopsies, biopsy test and dye spray (as sole procedure) | Intermediate | £440.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1281 | Removal and/or replacement of an embedded / migrated Mirena coil (as sole procedure) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2151 | Arthrocentesis of temporomandibular joint - unilateral | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2152 | Arthrocentesis of temporomandibular joint - bilateral | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q2330 | Salpingectomy (including bilateral) (as sole procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 14.2 | Suspension | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6720 | Laser treatment for glaucoma e.g. Cyclodiode | Intermediate | £350.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T3610 | Omental biopsy +/- an ascitic drain under image guidance | Intermediate | £350.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1730 | Extra-oral fixation of mandible | Intermediate | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1300 | Bypass of colon | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q2231 | Laparoscopic oophorectomy and salpingectomy, +/- biopsy eg. omentum, peritoneum, lymph node (as sole procedure) ? unilateral | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H6840 | Flexible pouchoscopy +/- biopsy and/or removal of polyp(s) | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4244 | Tibial liner exchange in total knee replacement | Complex | £1,200.00 | £584.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0390 | Extracorporeal septoplasty | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5810 | Diagnostic intracardiac electrophysiological study including characterisation of intracardiac conduction and any testing of anti-arrhythmic drug efficacy by programmed stimulation | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q5450 | Laparoscopic hysteropexy (including sacrohysteropexy) using mesh +/- ureterolysis | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1020 | Modified radical mastoidectomy (including meatoplasty) | Xmajor | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6070 | Implant of temporary pacing electrode (as sole procedure) | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7231 | Open release of constriction of sheath of tendon (e.g. trigger finger) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T7232 | Percutaneous release of constriction of sheath of tendon (e.g. trigger finger) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7602 | Microvascular free tissue transfer (when added to other codes) including closure of secondary defect | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7403 | Laparoscopic ileostomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1421 | Fat Plug Myringoplasty | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5540 | Seton placement for treatment of anal fistula | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| H5541 | Adjustment or removal of Seton under general anaesthetic | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5322 | Injection of therapeutic substance into keloid scar | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3740 | Second, third or further revision total hip replacement (excluding acetabular liner and head changes) | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W3741 | Proximal Femoral Replacement | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5500 | Total pancreatectomy and excision of surrounding tissue | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6051 | Aqueous shunt tube surgery for glaucoma (including topical or local anaesthetic) including donor patch - unilateral | Intermediate | £400.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| C6052 | Aqueous shunt tube surgery for glaucome (including topical or local anaesthetic) including donor patch - bilateral | Intermediate | £600.00 | £291.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.1 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR287 | Catheter cerebral venography and manometry | Intermediate | £500.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2012 | Replantation of ureter into bowel (including bilateral) | Xmajor | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5810 | Patella resurfacing (as sole procedure) | Major | £350.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q2232 | Open oophorectomy and salpingectomy, +/- biopsy eg. omentum, peritoneum, lymph node (as sole procedure) - unilateral | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2510 | Laparoscopic repair of paratomal hernia requiring mesh | Intermediate | £470.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR930 | BILATERAL INFERIOR PETROSAL SINUS SAMPLING | MAJOR | £0.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q2233 | Open oophorectomy and salipingectomy, +/- biopsy e.g. omentum, peritoneum, lymph node (as sole procedure) - bilateral | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0721 | Eminectomy of temporomandibular joint - unilateral | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V0722 | EMINECTOMY OF TEMPOROMANDIBULAR JOINT - BILATERAL | INTERMEDIATE | £600.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.12 | Urinary | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR661 | Insertion of stent into ureters - bilateral | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3100 | Bone graft (as sole procedure) | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7430 | Reconstruction of lateral collateral ligament complex | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W7530 | Repair of lateral collateral ligament complex | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W7430 | Reconstruction of lateral collateral ligament complex | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0380 | Fusion of first metatarso-phalangeal joint – bilateral | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR915 | Insertion of central venous catheter-tunnelled (X-ray guided) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3382 | Proctectomy | Major | £600.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4900 | Percutaneous transluminal angioplasty of coronary artery(ies) (including laser) | Complex | £900.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0950 | Radical clearance of sarcoma of trunk or limbs, +/- amputation or insertion of prosthesis | Complex | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR361 | Prostate Artery Embolisation | major | £500.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2999 | Reconstruction of breast using stacked deep inferior epigastric perforator flap (DIEP) (including delayed reconstruction) - unilateral (2 flaps) | Complex | £2,750.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9030 | Injection(s) +/- aspiration, into joint, cyst, bursa with image guidance | Minor | £115.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2501 | FIBRE OPTIC EXAMINATION OF THE PHARYNX +/- BIOPSY/REMOVAL OF FOREIGN BODY | MINOR | £50.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2162 | Therapeutic arthroscopic operation of temporomandibular joint +/- lysis and/or lavage - bilateral | intermediate | £475.00 | £454.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2161 | Therapeutic arthroscopic operation of temporomandibular joint +/- lysis and/or lavage -unilateral | intermediate | £350.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V2161 | Therapeutic arthroscopic operation of temporomandibular joint +/- lysis and/or lavage -unilateral | intermediate | £350.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4081 | Anterolateral access with instrumentation +/- decompression +/- duscectomy (including graf stabilisation and all fusion approaches) -lumbar region (3 or more levels) | Complex | £1,500.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V4081 | Anterolateral access with instrumentation +/- decompression +/- duscectomy (including graf stabilisation and all fusion approaches) -lumbar region (3 or more levels) | Complex | £1,500.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.1 | Spinal column (including intervertebral discs) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4080 | Anterolateral access with instrumentation +/- decompression +/- discectomy (including graf stabilisation & all fusion approaches) lumbar region (1 or 2 levels) | Complex | £1,500.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V3300 | Percutaneous intradiscal laser ablation (lumbar region) | Major | £700.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V5487 | Pedicle based dynamic semi-rigid stabilisation procedure (e.g accuflex) | £900.00 | £428.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| V5486 | Pedicle based dynamic soft stabilisation procedure (e.g graf ligament) | Extra Major | £900.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6110 | Laser trabeculoplasty (including topical or local anaesthetic) – bilateral | Intermediate | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G1400 | VATS excision lesion of oesophagus | Xmajor | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7361 | Complex Urethroplasty, Eg Revision Surgery of the Anterior Urethra, Segment, Posterior Urethra, +/- Grafting (Including Cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR365 | Magnetic Resonance Image-Guided Focused Ultrasound For Ablation of Uterine Fibroids | Complex | £900.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6580 | Tendon graft, or tendon transfer (as sole procedure, not otherwise specified) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3335 | Endoscopic vaccum therapy for colorectal anastomotic leakage | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8562 | LAPAROSCOPIC PELVIC LYMPHADENECTOMY (AS SOLE PROCEDURE) | Major | £600.00 | £298.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4300 | Transoral laser microsurgery, including pharyngotomy, partial laryngectomy, partial glossectomy and/ or tracheostomy | Complex | £2,000.00 | £1,299.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G1421 | Endoscopic focal ablation of dysplasia in Barrett's oesophagus | Intermediate | £400.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5611 | LAPAROSCOPIC PANCREATODUODENECTOMY AND EXCISION OF SURROUNDING | complex | £1,900.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5211 | Injection of Botulinum Toxin for Hyperhidrosis | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5532 | Dressing of burn of skin or subcutaneous tissue - less than 2% | Minor | £150.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.11 | Retina | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5480 | Removal of silicone oil | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7720 | Minimally Invasive Sacrolliac Joint Stabilisation Surgery for Chronic Sacrolliac Pain Under Image Guidance | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22029 | Home sleep study including reporting | Minor | £700.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR161 | Percutaneous image guided fine needle aspiration(s) (FNA) – bilateral | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1110 | Diagnostic endoscopic examination of kidney (including biopsy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2590 | Revision of anti-reflux procedures | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4514 | Endoscopic Examination of Bladder (Rigid Cystoscopy) Including any Biopsy | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5101 | Laser haemorrhoidectomy (including sigmoidoscopy) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H2002 | Diagnostic colonoscopy, includes forceps biopsy of colon and ileum | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6880 | Insertion of Prostatic Urethral Lift Implants (Including Cystoscopy) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 12.6 | Genitalia | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2820 | Reconstruction of penis | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 20.0 | Radiotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X6004 | Forward planning and preparation for the delivery of intensity modulated radiotherapy (IMRT), including adaptive IMRT | £800.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6005 | Inverse planning and preparation for the delivery of intensity modulated radiotherapy (IMRT), including adaptive IMRT | £1,000.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6002 | Planning and preparation for the delivery of Stereotactic Body radiotherapy (SBT)/Stereotactic Ablative radiotherapy (SABR) | £1,350.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6003 | Planning and preparation for the delivery of Stereotactic Radiosurgery (SRS) | £1,350.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6006 | Planning and preparation for the delivery of static total body irradiation (TBI) | £300.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6007 | Planning and preparation for the delivery of rotational total body irradiation (TBI) | £500.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6009 | Planning and preparation for the delivery of Selective Internal Radiotherapy (SIRT) | £600.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6010 | Planning and preparation for the delivery of 3D conformal radiotherapy (3DCRT) | £600.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6011 | Planning and preparation for the delivery of superficial radiotherapy with imaging, dosimetry and calculation using orthovoltage | £200.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6012 | Planning and preparation for the delivery of magnetic resonance image (MRI) radiotherapy | £1,350.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6013 | Planning and preparation for the delivery of Proton Beam Therapy (PBT) for ocular tumours | £1,350.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6016 | Planning for electrons, single field or 2-dimensional radiotherapy on a megavoltage machine, including all imaging and dosimetry | £300.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X0010 | Clinical supervision of intraoperative radiation therapy (IORT) | £360.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT260 | Planning for insertion and removal of radioactive agent (brachytherapy) into carcinoma of the oesophagus, bronchus or stomach | £360.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X0007 | Clinical supervision of external beam radiotherapy, up to and including 15 fractions or part thereof | £380.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X0008 | Clinical supervision of external beam radiotherapy, for 16 or up to and including 30 fractions | £720.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X0009 | Clinical supervision of external beam radiotherapy, for 31 or more fractions | £750.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X0011 | Consultant supervision of the delivery of a single fraction of orthovoltage radiotherapy | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X7009 | Delivery of Selective Internal Radiotherapy (SIRT) | £360.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT270 | Insertion and removal of radioactive agent (brachytherapy) into carcinoma of the oesophagus, bronchus or stomach | £360.00 | £259.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F5121 | COMBINED OPEN AND ENDOSCOPIC REMOVAL OF SUBMANDIBULAR GLAND STONE | intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| F5611 | COMBINED OPEN AND ENDOSCOPIC REMOVAL OF PAROTID GLAND STONE | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K0960 | Minimally invasive endoscopic repair of atrial septal defects (ASD) via mini-thoracotomy | Complext | £2,300.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.0 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| R1230 | Transabdominal cerclage for cervial incompetence in gravid uterus | Intermediate | £360.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| R1240 | Laparoscopic cerclage for cervial incompetence in gravid uterus | Intermediate | £360.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E6710 | Bronchial thermoplasty (including bronchoscopy) for severe asthma | Minor | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J9901 | Cytoreductive surgery (Sugarbaker technique) for Pseudomyxoma Peritonei with intraperitoneal chemotherapy | Complex | £4,000.00 | £2,339.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| J9902 | Cytoreductive surgery for Colorectal Peritoneal Carcinomatosis (2-3 distinct precedures) with intraperitoneal chemotherapy | Complex | £2,125.00 | £1,039.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| J9904 | Cytoreductive Surgery for Colorectal Peritoneal Carcinomatosis (7-8 distinct procedures) with intraperitoneal chemotherapy | Complex | £3,625.00 | £2,143.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| J9905 | Repeat Cytoreductive Surgery for Pseudomyxoma Peritoneal or Colorectal Peritoneal Carcinomatosis with intraperitoneal chemotherapy | Extra Major | £1,350.00 | £844.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| J9906 | Heated Intraperitoneal Chemotherapy For Colorectal Peritoneal Carcinomatosis | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| J9907 | Cytoreductive surgery for Ovarian Malignancies excluding intraperitoneal chemotherapy | Complex | £1,350.00 | £844.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 20.0 | Radiotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT211 | Planning for insertion and removal of high dose rate radioactive agent (brachytherapy) into prostate tumour | £1,350.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT251 | Planning for insertion and removal of radioactive agent (brachytherapy) into rectal tumour | £360.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT281 | Planning for insertion and removal of radioactive agent (brachytherapy) into the vagina | £360.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT341 | Planning for insertion and removal of a radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | £360.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1060 | Fiducial Placement | £210.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 20.0 | Radiotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1060 | Fiducial Placement | £210.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT252 | Insertion and removal of radioactive agent (brachytherapy) into rectal tumour | £360.00 | £259.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT282 | Insertion and removal of radioactive agent (brachytherapy) into the vagina | £360.00 | £259.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT342 | Insertion and removal of a radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | £360.00 | £259.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT212 | Insertion of low dose rate radioactive agent (brachytherapy) into prostate tumour | £800.00 | £571.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT222 | Insertion and removal of high dose rate radioactive agent (brachytherapy) into prostate tumour | £800.00 | £571.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT253 | Low energy contact X ray brachytherapy (the Papillon technique) for early stage rectal cancer | £200.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2730 | Colposcopy (+/- Biopsy, Polypectomy or Vulvoscopy) | £100.00 | £129.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J9903 | Cytoreductive surgery for coloretal peritoneal carcinomatosis (4-6 distinct procedures) with intraperitoneal chemotherapy | Complex | £2,750.00 | £1,363.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4500 | Extracapsular Dissection of Parotid Tumour | Extra Major | £1,000.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5031 | 2 Stage Revision of Total Shoulder Replacement For Infection - First Stage | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5032 | 2 stage revision of total shoulder replacement for infection - second stage | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.0 | Abdomen (excluding urinary and reproductive organs) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3042 | Mastectomy and immediate reconstruction of breast using expandable prosthesis - bilateral | Extra Major | £825.00 | £534.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| B3043 | Mastectomy and immediate reconstruction of breast using fixed prosthesis - bilateral | Extra Major | £825.00 | £534.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR363 | Portal vein embolisation (as sole procedure) | Complex | £900.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2981 | LOCAL MOBILISATION OF GLANDULAR BREAST TISSUE TO FILL SURGICAL CAVITY | INT | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0330 | Cone biopsy of cervix uteri and/or (+/- laser, colposcopy or polypectomy) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H6050 | Endoscopic Ablation for a Pilonidal Sinus | Intermediate | £250.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| H5561 | Endoscopic ablation for an anal fistula with flap | Intermediate | £350.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8645 | Multiple arthroscopic operations on ankle (including soft tissue, bony and/or joint surface procedures with ligament reconstruction). | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W8646 | Multiple arthroscopic operations on ankle (including soft tissue, bony and/or joint surface procedures without ligament reconstruction) | Major | £500.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1400 | Pulmonary endarterectomy | Complex | £2,500.00 | £1,299.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4210 | Endoscopic resection of lesion of bladder (including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3751 | Customised unilateral hip replacement | Extra Major | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4070 | Stabilisation of pars defect + /- instrumentation +/- bone graft +/- spinal monitoring | Extra Major | £1,000.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| V4070 | Stabilisation of pars defect + /- instrumentation +/- bone graft +/- spinal monitoring | Extra Major | £1,000.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G1422 | Endoscopic Circumferential Ablation Of Dysplasia In Barrett's Oesophagus | Intermediate | £400.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.6 | Rectum/anus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5941 | Excision of pilonidal sinus with flap reconstruction | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2281 | Closure of left atrial appendage (other than percutaneous) in association with other cardiac surgery | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X4120 | Removal of Tenckhoff catheter | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3820 | Cystostomy and insertion of suprapubic tube into bladder (including cystoscopy) | Intermediate | £200.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5530 | Closure of anal fistula using a suturable bioprosthetic or synthetic plugs +/- image guidance | Intermediate | £270.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S6040 | Scar Revision up to 5cm - Head & Neck | Minor | £175.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| S6041 | Scar revision up to 5cm - trunk & limbs | Minor | £175.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| S6042 | Scar Revision over 5cm - Head & Neck | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| S6043 | Scar revision over 5cm - trunk & limbs | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7070 | Percutaneous electrical nerve stimulation (PENS) | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5131 | Ultraviolet irradiation of riboflavin for epithelium off cross linking of corneal collagen | Major | £750.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7123 | Phacoemulsification of cataract, without lens implant - unilateral (including topical or local anaesthetic) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2240 | Balloon dilatation of the eustachian tube | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3100 | Reduction mammoplasty - unilateral | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| B3120 | Augmentation Mammoplasty - Unilateral | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| B3130 | Unilateral Mastopexy | Extra Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1818 | Reverse Ptosis Repair of Eyelid | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0310 | Reconstruction of external ear for anotia/microtia using cartilage | Complex | £1,350.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P1300 | Operations on female perineum | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| P2000 | Excision of lesion of vagina (e.g. warts and cysts) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2224 | Robotic Assisted Laparoscopic Adrenalectomy - Bilateral | Extra Major | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| B2234 | Robotic Assisted Laparoscopic Adrenalectomy | Major | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| J5712 | Robotic Assisted Distal Pancreatectomy | Extra Major | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.9 | Abdominal wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2620 | Repair of recurrent incisional hernia requiring mesh | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2640 | Repair of recurrent incisional hernia requiring removal of previously inserted mesh | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0610 | Biopsy of lesion of pinna (as sole procedure) | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L3330 | Endovascular Insertion Of An Intrasaccular Wire-Mesh Blood-Flow Disruption Device For Intracranial Aneurysms | Extra Major | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2601 | Sutureless aortic valve replacement for aortic stenosis | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3780 | Injection of botulinum toxin into extraocular or periocular muscles | Intermediate | £300.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N3032 | Revision of Circumcision | Intermediate | £220.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6920 | Paracentesis of the eye | Intermediate | £300.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5580 | Endoscopic Ablation for an Anal Fistula without Flap | Intermediate | £250.00 | £233.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6583 | Transperinal MRI - US Fusion Targeted Prostate Biopsy | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| M6584 | Transrectal MRI - US Fusion Targeted Prostate Biopsy | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0214 | Minimally invasive pectus bar placement for pectus excavatum (including bilateral) | extra major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T0215 | Open surgical correction of pectus deformity of chest wall (or other congenital defect thereof) | Complex | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T0213 | Removal of pectus bar (including bilateral) | Intermediate | £400.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2140 | Reconstruction using stomach pull up following pharyngolaryngectomy | Complex | £1,750.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3742 | 2 Stage Revision Of Total Hip Replacement For Infection - First Stage | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4180 | Distraction Of Spinal Magnetic Growth Rods For Idiopathic Juvenile Scoliosis | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3743 | 2 Stage Revision Of Total Hip Replacement For Infection - Second Stage | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2203 | Repair Of Femoral Hernia Requiring Removal Of Previously Inserted Mesh | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2003 | Repair Of Inguinal Hernia Requiring Removal Of Previously Inserted Mesh | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2403 | Repair Of Umbilical/Paraumbilical Hernia Requiring Removal Of Previously Inserted Mesh | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2581 | Minimally Invasive Mitral Valve Repair | Complex | £2,000.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8550 | Bioadhesive Closure Of Varicose Veins Using Cyanoacrylate - Unilateral | Intermediate | £250.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| L8551 | Bioadhesive Closure Of Varicose Veins Using Cyanoacrylate - Bilateral | Intermediate | £400.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0200 | Partial hepatectomy (left hepatectomy or resection of up to three segments) +/- choleycystectomy | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5773 | Facet joint injection +/- image guidance (including bilateral) cervical | Intermediate | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5753 | Nerve root block +/- image guidance (including bilateral) cervical | Intermediate | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G8085 | THERAPEUTIC OESOPHAGO-GASTRO-DUODENOS (OGD)&IMMEDIATE FLEXIBLE SIGMOIDOSCOPY | INTERMEDIATE | £275.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| G8085 | THERAPEUTIC OESOPHAGO-GASTRO-DUODENOS (OGD)&IMMEDIATE FLEXIBLE SIGMOIDOSCOPY | INT | £275.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5754 | Nerve Root Block +/- Image Guidance (Including Bilateral) Thoracic | Intermediate | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5755 | Nerve root block +/- image guidance (including bilateral) lumbar | Intermediate | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5774 | Facet joint injection +/- image guidance (including bilateral) thoracic | Intermediate | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5756 | NERVE ROOT BLOCK +/- IMAGE GUIDANCE (INCLUDING BILATERAL) CAUDAL | INTERMEDIATE | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5775 | Facet joint injection +/- image guidance (including bilateral) lumbar | Intermediate | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5766 | Neurolytic Root Block (Radiofrequency denervation, Thermocoagulation, Cryotherapy or Phenol, including Rhizolysis) +/- Image Guidance (including Bilateral) CAUDAL | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5765 | Neurolytic Root Block (Radiofrequency denervation, Thermocoagulation, Cryotherapy or Phenol, including Rhizolysis) +/- Image Guidance (including Bilateral) LUMBAR | MAJOR | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5763 | Neurolytic Root Block (Radiofrequency denervation, Thermocoagulation, Cryotherapy or Phenol, including Rhizolysis) +/- Image Guidance (including Bilateral) CERVICAL | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5764 | Neurolytic Root Block (Radiofrequency denervation, Thermocoagulation, Cryotherapy or Phenol, including Rhizolysis) +/- Image Guidance (including Bilateral) THORACIC | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G8084 | Diagnostic Oesophago-Gastro-Duodenos (OGD) & Immediate Flexible Sigmoidoscopy | Intermediate | £275.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 20.0 | Radiotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X6019 | Planning And Preparation For The Delivery Of MR Linac Adaptive Planned Radiotherapy | £800.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7213 | Paediatric Cataract Involving Lensectomy With Lens Implant Bilateral | Major | £525.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| C7212 | Paediatric cataract involving lensectomy with lens implant unilateral | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| C7211 | Paediatric Cataract Involving Lensectomy Without Lens Implant Bilateral | Major | £525.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 20.0 | Radiotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X7019 | Delivery of a Fraction MR Linac Adaptive Planned Radiotherapy, Including Image Guidance | £500.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7215 | Paediatric Cataract Involving Lens Aspiration And Implant Bilateral | Major | £525.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| C7214 | Paediatric cataract involving lens aspiration and implant unilateral | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 18 | Chemotherapy | |||||||||||||||||||||||||||||||||||||||||||||||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
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| 18.0. | Chemotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| x0005 | Clinical supervision and planning for delivery of chemotherapy And/Or Systemic Anti-Cancer Therapy For 1-56 Days | Non | £1,000.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7210 | Paediatric cataract involving lensectomy without lens implant unilateral | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9000 | Open removal of thrombus from vein | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.7 | Teeth | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L0200 | Closed ligation of patent ductus arteriosus | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8500 | Multiple arthroscopic operation on knee (including meniscectomy, chondroplasty, drilling or microfracture) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1920 | Partial pharyngectomy | Xmajor | £650.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X7001 | Planning And Delivery Of Intraoperative Radiation Therapy (IORT) | £500.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X3060 | Sub-tenons anaesthesia administered by anaesthetist (as sole procedure) | MIN | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.5 | Mouth cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F1140 | Vestibuloplasty | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X6575 | Planning, preparation and the delivery of peptide receptor radionuclide therapy for neuroendocrine tumours. | £200.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2510 | Endoscopic discectomy and/or decompression (transforaminal) - lumbar region | Extra Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3384 | Open Total Mesorectal Excision (TME) | Complex | £1,700.00 | £909.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| H3385 | Laparoscopic Total Mesorectal Excision (TME) | Complex | £1,700.00 | £909.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5744 | Medial Branch Block Injection(s) +/- Image Guidance (Including Bilateral) Thoracic | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3309 | Removal And Reinsertion Of Existing Prosthesis Into The Breast (Including Capsulectomy) - Bilateral | Major | £600.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5745 | Medial branch block injection(s) +/- image guidance (including bilateral) LUMBAR | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5743 | Medial branch block injection(s) +/- image guidance (including bilateral) CERVICAL | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 20.0 | Radiotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X7020 | Delivery of a fraction of Total body surface skin radiotherapy (TSEBT) | £360.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| X6020 | Planning and preparation of the delivery of Total body surface skin radiotherapy (TSEBT) | £600.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2764 | Open repair of Spigelian hernia without mesh | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2762 | Open repair of Spigelian hernia with mesh | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.11 | Retina | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C8810 | Transpupillary thermotherapy for intraocular tumours | Intermediate | £200.00 | £161.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2761 | Laparoscopic Repair of Spigelian Hernia with Mesh | Intermediate | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2782 | Minimally invasive Component Separation Technique (CST) repair for complex abdominal hernia with mesh | Extra Major | £1,500.00 | £779.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T2784 | Minimally Invasive Component Separation Technique (CST) Repair For Complex Abdominal Hernia Without Mesh | Extra Major | £1,500.00 | £779.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6030 | Transection of peripheral nerve for neuroma | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| T7483 | Ultrasound guided barbotage of calcific deposits of joint (as sole procedure) | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2783 | Open Component Separation Technique (CST) repair for complex abdominal hernia without mesh | Extra Major | £1,500.00 | £779.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 20.0 | Radiotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT210 | Oral introduction of liquid radioactive agent (Brachytherapy) for thyroid tumour ablation | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3700 | Removal of port or valve from expandable breast prosthesis +/- image guidance | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT213 | Planning, insertion and removal of high dose rate radioactive treatment (brachytherapy) into prostate tumour | £1,750.00 | £668.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| BT214 | Planning And Insertion Of Low Dose Rate Radioactive Treatment (Brachytherapy) Into Prostate Tumour | £1,450.00 | £668.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2150 | Reconstruction free jejunal graft following pharyngolaryngectomy | Complex | £1,750.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT215 | Planning for insertion of low dose rate radioactive treatment (brachytherapy) into prostate tumour | £1,050.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9132 | Removal of tunnelled central venous catheter (Hickman line) | MInor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K3501 | Therapeutic transluminal operation(s) on valve of heart | Extra Major | £750.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6630 | Primary closed reduction of fracture or dislocation of joint, with or without fixation including cast application | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0530 | Elevation of depressed fracture of cranium | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5703 | Thoracotomy bullectomy - bilateral | Complex | £1,300.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S1750 | Large muscle flap (9cm2 or more) including skin graft and closure of secondary defect | Xmajor | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22025 | Recording and reporting on electromyography and nerve conduction studies (EMG); Myaesthenia Gravis (+ SFEMG) | Minor | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3112 | Surgical correction of squint - unilateral | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0550 | Repair of kidney wound | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6580 | Endoscopic biopsy of prostate (including cystoscopy) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5590 | VATS bullectomy - unilateral | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.10 | Great Vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 | Investigations | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20150 | Patch testing (Inclusive of application, reading & reporting) | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S2000 | Large island skin flap (9cm2 or more) (eg radical forearm) including closure of secondary defect | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0610 | Extended excision of right hemicolon | Xmajor | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6960 | Needle biopsy of synovium | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1880 | Laparoscopically assisted left colon resection | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1931 | Alveolar bone graft - bilateral | Intermediate | £600.00 | £324.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9020 | Sentinel node mapping and sampling with blue dye and radioactive probe for breast cancer | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2100 | Other connection of ureter | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| M2530 | Ureterolysis ? unilateral | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5580 | CSF infusion studies | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.3 | Paraspinal injections | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25010 | Paravertebral block up to two levels (without X-ray control) | £120.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3530 | Removal of percutaneous wire | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2660 | Revision of decompression for central spinal stenosis | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4400 | Urethral sphincterotomy (including cystoscopy) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6910 | Reformation of anterior chamber | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5210 | Epidural injection (lumbar) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6010 | Surgical trabeculectomy or other penetrating glaucoma procedures (including topical or local anaesthetic) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.3 | Renal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L4300 | Transluminal operations on renal artery | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0330 | Exploratory burr hole of cranium | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1980 | Elective repair of aneurysm of arch of aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7590 | Insertion of suburethral tape sling (e.g. TOT or TVT) +/- administration of local anaesthetic by operating surgeon (including cystoscopy) | Major | £370.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1641 | Osteotomy of short bone of hand (including fixation and bone grafting) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2580 | Repair of mitral valve | Complex | £2,000.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8532 | Operations for recurrent varicose veins without re-exploration of groin or popliteal fossa - unilateral | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1522 | Correction of entropion - lower lid | Intermediate | £360.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T4300 | Laparoscopic adhesiolysis (including biopsy) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4850 | Therapeutic bronchoscopy for removal of foreign body | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.8 | Elbow | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6782 | Repair of distal biceps tendon | Major | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1130 | Correction of epicanthus | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7352 | Image-guided local anaesthetic blockade of named major nerve or plexus | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2800 | Excision of breast lump/fibroadenoma | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7423 | Ligation of arteriovenous fistula for dialysis | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2743 | Modified radical mastectomy excluding lymph node sampling | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6410 | Tendon transfer of hand – multiple (eg for radial nerve injury) | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7920 | Dilatation of urethra (including cystoscopy) | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2230 | Posterior colporrhaphy | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8530 | Operations for recurrent varicose veins with re-exploration of groin and/or popliteal fossa - unilateral | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2330 | Transabdominal repair of hiatus hernia | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7250 | Ileoanal anastomosis and creation of pouch | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7482 | Scaphoid lunate ligament reconstruction | Major | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8230 | Arthroscopic meniscal repair | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25150 | Trigeminal ganglion injection (local anaesthetic under X-ray control) | Intermediate | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| A5420 | Injection of therapeutic substance into CSF | Minor | £100.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3440 | Closure of Gastrostomy | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.9 | Abdominal wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2750 | Repair of sciatic hernias | Intermediate | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0922 | Laser destruction of lesion(s) of skin - up to 25cm² in area | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4212 | Minimally invasive knee replacement | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0840 | Orbital injection | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0280 | Removal of multiple boney exostoses EAC | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1380 | Bilateral fixation of testis | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 6.8 | Neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8610 | Biopsy/sampling of cervical lymph nodes | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8.10 | Great Vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2220 | Puncture of cistern of brain | Minor | £150.00 | £181.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2781 | Lue's procedure for Peyronie's disease | Intermediate | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7125 | Ultrasound phacoemulsification of cataracts, with lens implant - bilateral (including topical or local anaesthetic) | Major | £525.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2752 | Subcutaneous mastectomy | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2640 | Freeing of adhesions of tongue | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0654 | Removal of benign lesion on head and neck (excluding scalp) which is closed by primary closure or advancement flap (excluding lipoma) | Intermediate | £210.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4240 | 2 stage revision of total knee replacement for infection – first stage | Xmajor | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5594 | VATS debridement of empyema | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1440 | Excision of lesion of jaw | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3810 | Reconstruction of breast using SGAP (superior gluteal artery perforator) flap including delayed reconstruction. | Complex | £2,500.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6832 | Second stage reconstruction of flexor of hand | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5481 | Pancreatic with kidney transplant (simultaneous pancreas SPK) | Complex | £2,200.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7520 | Lens implant/exchange | Major | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T3980 | Excision of presacral tumour | Intermediate | £400.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6700 | Release of entrapment of peripheral nerve | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0606 | Photodynamic therapy (PDT) to malignant lesion of skin - up to three | Intermediate | £250.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5300 | Vaginal operations to support outlet of female bladder (including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K3500 | Therapeutic transluminal operation(s) on valve of heart | Xmajor | £750.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3032 | Removal of fixator/frame/pins/wires and change of plaster (as sole procedure) | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2320 | Transthoracic repair of diaphragmatic hernia (acquired) | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V1423 | Extensive excision of mandible with disarticulation | Xmajor | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0221 | Nephroureterectomy - bilateral | Xmajor | £900.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1940 | Primary open reduction of short bone with fixation (including intra-articular) | Intermediate | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0100 | Open hypophysectomy (including total) | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT212 | Insertion of low dose rate radioactive agent (brachytherapy) into prostate tumour | £800.00 | £571.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1230 | Curettage/cryotherapy of lesion of eyelid | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2280 | Primary repair of strangulated femoral hernia | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1300 | Transluminal operations on pulmonary artery | Xmajor | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6420 | Excision of lesion of iris | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5250 | Endoscopic plantar fascia release | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G5000 | Open excision of lesion of duodenum | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3140 | VATS percutaneous discectomy +/- fusion (thoracic region) including spinal cord monitoring | Xmajor | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2740 | Repair of perineal hernia including scrotal that are not inguinal | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6450 | Tenodesis of biceps tendon (as sole procedure) | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9510 | Venography (and bilateral) | Minor | £150.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N2710 | Excision of lesion of penis | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0284 | Total excision of trapezium and ligament reconstruction | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0860 | Metatarso-phalangeal cheilectomy - unilateral, as sole procedure | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0514 | Reconstruction of socket with implant and graft | Complex | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5600 | Primary repair of rupture of acromioclavicular or sternoclavicular joint +/- internal fixation | Xmajor | £750.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2890 | Push manipulation of stone prior to lithotripsy (as sole procedure) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5712 | Debridement of wound (and surgical toilet) - over 25cm² in area | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6400 | Repair of peripheral nerve | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0640 | Total excision of sesamoid bone | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7520 | Repair of acquired arteriovenous fistula | Complex | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S2002 | Small island flap (less than 9cm2) | Intermediate | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1110 | Excision of lesion of canthus | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7340 | Exploration and grafting of brachial plexus | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0410 | Panproctocolectomy and ileostomy | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.11 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2730 | Highly selective vagotomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0822 | Amputation of whole ray | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.12 | Urinary | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR670 | Radiofrequency kidney ablation | Complex | £1,100.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F3620 | Drainage of peritonsillar abscess ('quinsy') | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1980 | Elective repair of aneurysm of arch of aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0810 | Excision of lesion of external auditory canal | Minor | £150.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5940 | Fusion of interphalangeal joint(s) of toe (including internal fixation) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4880 | Correction of anomalous coronary arteries | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X1410 | Total exenteration of pelvis | Complex | £1,600.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 | Abdominal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1680 | Axillo-bifemoral bypass | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2130 | Ileal or colonic replacement of ureter | Complex | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W5201 | Unicompartmental knee replacement - bilateral | Complex | £1,150.00 | £519.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2420 | Insertion of cochlear implant | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X1110 | Amputation of toe | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0340 | Soft tissue meatoplasty of EAC | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K0500 | Atrial inversion for transposition of great vessels | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S3625 | Full thickness graft, head, neck, hands and genitalia each additional 16cm2 in area | Minor | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.11 | Retina | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2030 | Bilateral replantation of ureter into bladder | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8200 | Arthroscopic meniscectomy (including debridement) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2310 | Excision/destruction of lesion of tongue | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1040 | Osteotomy of short bone of foot (excluding hallux valgus and including internal fixation) | Intermediate | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2912 | Application of halo (as sole procedure) | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E6200 | VATS excision lesion of mediastinum including thymectomy | Xmajor | £600.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0260 | Transplant nephrectomy | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4242 | 2 stage revision of total knee replacement for infection – second stage | Xmajor | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J1830 | Laparoscopic cholecystectomy | Xmajor | £700.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1690 | Mediastinal parathyroidectomy with sternotomy | Complex | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0120 | Pollicisation of finger for thumb reconstruction | Complex | £1,000.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 | Abdominal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1940 | Open infrarenal abdominal aortic aneurysm tube graft | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4400 | Carinal resection +/- pneumonectomy | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.7 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR320 | Dilatation/stenting of nasolacrimal duct under imaging control | Major | £550.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.6 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0410 | Transsphenoidal hypophysectomy (including total) | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1542 | Closure of colostomy | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.8 | Neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8722 | Selective dissection of cervical lymph nodes, levels 1 to 4 | Xmajor | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5923 | Femoro-popliteal bypass using vein | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H2503 | Therapeutic sigmoidoscopy with snare loop biopsy or excision of lesion | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25022 | Stellate ganglion block (local anaesthetic) +/- Image Guidance | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 | Abdominal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2600 | Percutaneous transluminal balloon operations on aorta | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J6980 | Laparoscopic splenectomy | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.12 | Urinary | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR660 | Insertion of stent into ureters - unilateral | Major | £400.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0812 | Removal of solitary osteoma of EAC | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2331 | Laparoscopic repair of hiatus hernia with anti-reflux procedure (eg fundoplication) | Major | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T4680 | Suprapubic drainage of pelvic abscess | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0643 | Excision of lesion of skin or subcutaneous tissue - four or more, Trunk & Limbs (excluding lipoma) | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2310 | Anterior +/- posterior colporrhaphy (including primary repair of enterocele) (including cystoscopy) | Major | £570.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4740 | Image guided percutaneous spinal biopsy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR260 | Angioplasty with insertion of metallic stent | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3000 | Endoscopic examination of ureter (+/- cystoscopy and insertion/removal of stent) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4850 | Therapeutic bronchoscopy for removal of foreign body | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0412 | De-roofing and aspiration of renal para pelvic cyst | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6610 | Ciliary body ablation | Intermediate | £360.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 4.11 | Retina | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0820 | Excision of lesion of internal nose | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1600 | Therapeutic transluminal operations on atrial septum of heart | Complex | £800.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q3110 | Removal of products of conception from fallopian tube (ectopic pregnancy) including laparoscopically | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8700 | Diagnostic arthroscopic examination of joint, with or without biopsy (not otherwise specified) (as sole procedure) | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0513 | Reconstruction of socket with either implant or graft | Complex | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2953 | Excision of acoustic neuroma (vestibular schwannoma) - tumours more than 2.5cm or compressing brain stem (performed by single surgeon) | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2610 | Ross procedure | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5043 | Primary repair of low congenital anorectal anomaly | Xmajor | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.10 | Vitreous | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 18 | Chemotherapy | |||||||||||||||||||||||||||||||||||||||||||||||||
| These fees are intended to be all inclusive including consultations. Consultations for purposes other than
chemotherapy can be claimed as extra. |
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| 18.0. | Chemotherapy | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0003 | Clinical supervision and planning for delivery of chemotherapy And/Or Systemic Anti-Cancer Therapy for 1-21 Days | £375.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1590 | Correction of retracted/dislocated metatarso-phalangeal joint including tendon transfer, division/realignment of bone and internal fixation | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S2220 | Neurovascular island flap | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L6530 | Revision femoral bypass graft | Xmajor | £750.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X4110 | Open insertion of Tenckhoff catheter | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.6 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A8300 | Electro-convulsive therapy | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4213 | Debridement and primary suture of wound without involvement of deeper tissue (skin and subcutaneous fat only) - Trunk and Limbs | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2040 | Diagnostic tympanotomy (as sole procedure) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR917 | Peripherally inserted central venous catheters (PICCs) under X-ray guidance | Intermediate | £200.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| R1220 | Transvaginal removal of cerclage of cervix of gravid uterus | Minor | £150.00 | £181.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1720 | Revision stapedectomy (as sole procedure) | Xmajor | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7513 | Revision of ileostomy - laparotomy | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T3910 | Excision of retroperitoneal tumour, +/-ureterolysis | Xmajor | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J3100 | Open introduction of prosthesis into bile duct | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7520 | Thoracic sympathectomy diagnostic (local anaesthetic under X-ray control) | Intermediate | £300.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J6600 | Therapeutic percutaneous operations on pancreas | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6080 | Neurectomy (major nerve) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR964 | Liver Ablation (radiofrequency) | Complex | £1,100.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2360 | Repair of interrupted aortic arch | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1710 | Stapedectomy (as sole procedure) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3500 | Partial cystectomy (including cystoscopy) | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 12.6 | Genitalia | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1350 | Exploration of testis (including biopsy) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1690 | Mediastinal parathyroidectomy with sternotomy | Complex | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N0820 | Orchidopexy bilateral | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0321 | Osteotomy/ies (eg Scarf and Akin) for Hallux Valgus correction with or without internal fixation and soft tissue correction | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T0133 | Excision of chest wall tumour - without chest wall reconstruction | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2110 | Repair of recurrent inguinal hernia - bilateral | Xmajor | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6600 | Release of entrapment of deeply placed peripheral nerve | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2540 | Dacryocystorhinostomy (including insertion and later removal of tube) | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2820 | Wide local excision of breast +/- local mobilisation of glandular breast tissue to fill surgical cavity | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1210 | Excision of lesion of eyelid | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0412 | Reduction turbinates of nose (laser, diathermy, out fracture etc) | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2680 | Endoscopic removal and insertion of prosthesis into ureter (including cystoscopy) | Major | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7483 | Triquetrolunate ligament reconstruction | Major | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.3 | Duodenum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G5320 | Closure of perforated ulcer of duodenum | Major | £550.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A3330 | Removal of neurostimulator from cranial nerve | Major | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3220 | Core biopsy of lesion of breast | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7180 | Extracapsular cataract extraction with implant - unilateral | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Pregnancy and confinement | |||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 | Pregnancy and confinement | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1900 | Simple excision of inguinal hernial sac (herniotomy) - unilateral | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K1850 | Revision placement of valve to cardiac conduit | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2600 | Repair of recurrent incisional hernia not requiring mesh | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR920 | Cyst ablation under imaging control | Intermediate | £350.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25030 | Stellate ganglion block (neurolytic) +/- Image Guidance | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0420 | Triple fusion of joints of hindfoot without autogenous graft | Major | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2210 | Anterior +/- posterior colporrhaphy and amputation of cervix uteri (including primary repair of enterocele) | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2930 | Removal of prosthesis from ureter (including cystoscopy) | Minor | £180.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7310 | Biopsy of peripheral nerve | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8840 | Diagnostic arthroscopic examination of ankle including anterior synovectomy to gain vision (as sole procedure) | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.1 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A5300 | Drainage of spinal canal (including insertion of shunt) | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0830 | Correction of congenital atresia of choana (including endoscopic) | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3717 | Minimally invasive hip replacement (one incision) | Xmajor | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2542 | Revision replacement of mitral valve | Complex | £2,000.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0103 | Transplantation of kidney - 3rd transplant | Xmajor | £900.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B0812 | Total thyroidectomy/near total thyroidectomy | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0520 | Ligation of artery of internal nose (including endoscopic, as sole procedure) | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.7 | Teeth | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0910 | Surgical removal of impacted/buried tooth/teeth | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4480 | Therapeutic enteroscopy | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0980 | Thorascopic oesophagogastric myotomy | Major | £600.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 | Abdominal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L4530 | Endarterectomy and patch repair of visceral branch of abdominal aorta | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1643 | Open reduction/internal fixation of either posterior wall/column or acetabulum or anterior column of acetabulum | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.5 | Thrombolysis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR410 | Thrombolysis or aspiration of thrombus under imaging control | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5283 | Complex Cox lesion set maze operation | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8750 | Local excision (multiple phlebectomy) of varicose vein(s) of leg - unilateral | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1700 | Total reconstruction of eyelid - unilateral | Major | £550.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q2020 | Endometrial biopsy or aspiration | £100.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4980 | Tension sutures | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0700 | Excision of ectopic bone | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25140 | Intrathecal neurolysis | Intermediate | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR360 | Embolisation of vascular mass (including uterine embolisation) | Complex | £900.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0650 | Exploration of orbit (as sole procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20143 | Removal of implantable ECG loop recorder (including reporting) | £200.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0313 | Primary closure of cleft lip - bilateral | Major | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2600 | Therapeutic nephroscopic operations on ureter (including cystoscopy) | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0790 | Laparoscopic total hysterectomy (+/- oophorectomy) +/- ureterolysis | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3500 | Fixation of rectum for prolapse | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6160 | Complex glaucoma surgery (including anti-metabolites/insertion of seton devices) (including topical or local anaesthetic) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6710 | Primary repair of extensor of hand | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H2003 | Therapeutic colonoscopy with snare loop biopsy or excision of lesion | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 | Investigations | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20210 | Pure tone audiogram (air conduction) - including masking | £25.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1610 | Ossiculoplasty | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8100 | Open biopsy of muscle or soft tissue lesion | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2300 | Secondary open reduction of fracture of short bone (including intra-articular fracture for delayed/non-union and including bone graft) | Major | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H1200 | Excision of lesion of colon (transabdominal) | Major | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.8 | Major vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7980 | Repair of wound of major artery or vein of abdomen (including aorta and vena cava) | Major | £600.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.11 | Liver | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR575 | Percutaneous insertion of metallic biliary endoprosthesis | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.4 | Urethra | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5580 | Excision of urethral caruncle | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2602 | Minimally invasive replacement of aortic valve | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2110 | Oesophageal physiology studies (including pH measurement) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S1110 | Curettage/cryotherapy of lesion of skin including cauterisation - up to three | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7340 | Yag laser photodisruption of posterior capsule of lens (including laser capsulotomy) - unilateral | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1380 | Endoscopic balloon dilation sphenoid sinuplasty and bilateral | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.3 | Renal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L4140 | Endarterectomy of renal artery | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3700 | Repair of bladder (including cystoscopy) | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J1880 | Laparoscopic cholecystectomy with perioperative cholangiogram | Xmajor | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2780 | Repair of tricuspid valve, eg for Ebstein's disease | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F5120 | Open extraction of calculus from submandibular duct | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6460 | Tendon transfer of toe – unilateral | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3310 | Drainage of breast abscess including haematoma and seroma | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8540 | Block dissection of para-aortic lymph nodes | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0110 | Total excision of pinna | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6760 | Photoselective vaporisation of prostate (GreenLight/Niagara laser PVP) (including cystoscopy) | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.5 | Large intestine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0210 | Appendicectomy | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M6182 | Laparoscopic radical prostatectomy, reconstruction of bladder neck including bilateral pelvic lymphadenectomy (including cystoscopy) | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E6300 | Diagnostic mediastinoscopy | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.8 | Neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9420 | Operations on branchial fistula | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M8130 | External meatotomy of urethral orifice | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4730 | Percutaneous cordotomy of spinal cord | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4710 | Repair of corneal wound | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0200 | Excision of lesion of lip | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1540 | Surgical correction of trichiasis/upper lid entropion, including graft/flap | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4620 | Lamellar graft (keratoplasty) to cornea | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N3010 | Preputioplasty | Intermediate | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.8 | Spine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J0400 | Repair of liver (including therapeutic laparoscopic operations on liver) | Major | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| J3200 | Repair of bile duct | Xmajor | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4410 | Therapeutic oesophago-gastro-duodenoscopy (OGD) with insertion of prosthesis | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4910 | Closure of cystostomy | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1802 | Hysteroscopy with resection of fibroids (excluding morcellation) +/- insertion on Mirena coil | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5100 | Aorto-iliac, aorto-femoral, ilio-femoral bypass | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8380 | Therapeutic arthroscopy operation on articular cartilage (other than W8200) - bilateral (as sole procedure) | Major | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0632 | Excision of lesion of skin or subcutaneous tissue - up to three, Head & Neck (excluding lipoma) | Minor | £175.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J6900 | Open splenectomy | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X0910 | Hindquarter amputation | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H2502 | Diagnostic flexible sigmoidoscopy, including forceps biopsy and proctoscopy | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2810 | Repair of non-union of clavicle | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8520 | Ligation/stripping of long or short saphenous vein (including local excision/multiple phlebectomy) - bilateral | Major | £600.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR962 | Percutaneous chemical ablation of tumour - ultrasound guided | Intermediate | £1,100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3363 | Colectomy and colostomy and preservation of rectum | Xmajor | £750.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5222 | Dupuytren’s dermofasciectomy and graft, or for recurrent disease – single digit | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6810 | Decompression of cardiac tamponade or re-exploration for bleeding | Xmajor | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR130 | Transjugular/transfemoral plugged liver biopsy(ies) | Intermediate | £420.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7470 | Revision of anterior cruciate ligament reconstruction including autograft/allograft | Xmajor | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H2001 | Double balloon enteroscopy | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M7080 | Insertion of urethral stent for relief of prostatic obstruction (including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.7 | Teeth | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0950 | Surgical removal of complicated buried roots | Intermediate | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT342 | Insertion and removal of a radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | £360.00 | £259.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3780 | Repair of cutaneous vesical fistula | Intermediate | £350.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H4000 | Transanal resection of rectal cancer | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5540 | Fasciotomy of limb | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4410 | Total prosthetic replacement of ankle joint | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2420 | Sacrocolpopexy (including laparoscopic) +/- ureterolysis | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7400 | Reconstruction of one or two ligaments not elsewhere specified | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.6 | Hand | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7486 | Carpo-metacarpal joint ligament reconstruction | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6080 | Removal of pacing system without bypass (including leads) | Minor | £200.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR170 | Fluoroscopically guided drainage of fluid collection | Intermediate | £250.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6522 | Primary open reduction of dislocation of small joint | Intermediate | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0380 | Laparoscopic upper or lower pole heminephrectomy | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1340 | Biopsy of testis | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2940 | Partial laryngectomy | Complex | £1,000.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.3 | Renal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L4292 | Reconstruction of transplant renal artery | Xmajor | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S1420 | Shave biopsy of lesion of skin | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7580 | Repair arteriovenous fistula | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8800 | Diagnostic arthroscopic examination of hip joint including wash-out, with or without biopsy (as sole procedure) | Intermediate | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 | Thoracic vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1810 | Repair of leaking aneurysm of ascending aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.2 | Chest wall | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2781 | Repair of epigastric hernia | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T3600 | Wedge excision or removal of omentum (as sole procedure) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2744 | Modified radical mastectomy including lymph node clearance | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4100 | Insertion of voice prosthesis (TOF) | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1532 | Correction of trichiasis by electrolysis/diathermy/cryotherapy/laser | Minor | £175.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25011 | Paravertebral block up to two levels (under X-ray control) | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2620 | Frenotomy /frenectomy of tongue under general anaesthetic | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0812 | Open biopsy of renal transplant | Intermediate | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3590 | Stapled transanal rectal resection (STARR) for obstructed defaecation syndrome | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9730 | Isolated limb perfusion | Xmajor | £750.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4230 | Endoscopic destruction of lesion of bladder (including cystoscopy) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.4 | Nerve roots | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2912 | Mastectomy and immediate reconstruction of breast using latissimus dorsi | Xmajor | £1,250.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2500 | Primary posterior fusion +/- decompression +/- discectomy - lumbar region (1 or 2 levels) including spinal cord monitoring | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0610 | Packing of cavity of nose (as sole procedure) | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6300 | Graft to peripheral nerve | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.6 | Hand | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3203 | Early open reduction and internal fixation of scaphoid fracture ie within 6 weeks of fracture | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR940 | Retrieval of foreign body under X-ray guidance | Major | £450.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.11 | Retina | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0880 | Hysterectomy with excision / biopsy and/or removal of omentum and uterine adnexa for ovarian malignancy +/- ureterolysis | Xmajor | £850.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3719 | Hip Resurfacing Arthroplasty - Bilateral | Complex | £1,200.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5630 | Therapeutic injection into bladder neck for treatment of stress incontinence (periurethral bulking agents), including cystoscopy | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3712 | Primary total hip replacement with or without cement | Xmajor | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N3020 | Division of preputial adhesions | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0463 | Complex procedure to mid foot and hind foot without autogenous graft (osteotomy/fusion +/? tendon transfers/fixation) | Complex | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4840 | Dilatation of tracheal stricture including insertion of stent | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.6 | Peripheral nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6180 | Excision of lesion of major nerve | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5520 | Laying open of high anal fistula (fistulotomy) (including sigmoidoscopy) | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5180 | Revision combined abdominal and vaginal operations to support outlet of female bladder (including sling procedures and cystoscopy) | Xmajor | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2570 | Percutaneous vertebroplasty | Xmajor | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2312 | Transthoracic repair of paraoesophageal hiatus hernia | Xmajor | £800.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7915 | Arthroscopic rotator cuff repair greater than 2cm | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F2910 | Primary repair of cleft palate | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K0530 | Double switch procedure (atrial and arterial) | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4900 | Shoulder hemiarthroplasty, as sole procedure | Xmajor | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L0610 | Formation of atriopulmonary connection (or any modification of Fontan type procedure) | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8700 | Ligation/stripping of long and short saphenous veins (including local excision/multiple phlebectomy) | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C2910 | Puncto-canaliculoplasty | Minor | £320.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F5020 | Transposition of submandibular duct (including bilateral) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W2380 | Locked intramedullary nailing of fractured long bone | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR442 | Embolisation of varicocele of gonadal vein | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3400 | Open total cystectomy (with construction of intestinal conduit or bladder) | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0730 | Repair of congenital oesophageal atresia (with or without fistula) | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0110 | Toe to hand transfer (as sole procedure) including closure of secondary defect | Complex | £1,000.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K5330 | Repair of post infarction ventricular septal defect | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2080 | Ventricular puncture (as sole procedure) | Minor | £160.00 | £181.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7110 | Tenosynovectomy | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K0900 | Repair of complete atrioventricular septal defect | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25100 | Coeliac plexus block, splanchnic nerve block, hypogastric block - diagnostic +/- Image Guidance | Intermediate | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S5562 | Release of burn scar contracture, trunk and limbs | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5680 | Excision of pressure sore excluding repair | Intermediate | £250.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4210 | Tracheostomy | Intermediate | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2100 | Repair of pharynx | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6722 | Tendo Achilles lengthening primary open | Major | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L7422 | Creation of arteriovenous fistula for dialysis | Intermediate | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.2 | Eyebrow and lid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C1640 | Tarsorrhaphy | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0950 | Radical clearance of sarcoma of trunk or limbs, +/- amputation or insertion of prosthesis | Complex | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| BT341 | Planning for insertion and removal of a radioactive agent (brachytherapy) into cervix or other female intra-pelvic tissue | £360.00 | £194.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.12 | External fixation/traction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7050 | Lengthening of tendon(s), or open tenotomy | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 12.5 | Prostate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8002 | Minor release of muscle for pain or contracture (involving small joint) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0314 | Primary closure of cleft lip - unilateral including anterior palate | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5203 | Dupuytren’s fasciectomy single digit with proximal interphalangeal joint | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3212 | Percutaneous suction core biopsy | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2760 | Skin/Nipple sparing mastectomy (including axillary node biopsy) | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2223 | Adrenalectomy - bilateral (laparoscopic) | Xmajor | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0980 | Deep brain stimulation | Complex | £2,000.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X4822 | Change of cast under general anaesthetic (as sole procedure) | Minor | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L0310 | Percutaneous transluminal prosthetic occlusion of patent ductus arteriosus | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0382 | Total petrosectomy (for tumour) | Complex | £1,350.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2500 | Intracranial transection of cranial nerve | Complex | £1,600.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.5 | Ileo-femoral vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L5950 | Femoro-distal calf bypass using prosthesis +/- vein cuff/patch | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A3680 | Excision of cerebello-pontine angle tumour | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M3010 | Endoscopic retrograde pyelography (including bilateral and cystoscopy) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6540 | Open reduction of dislocated hip prosthesis | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4451 | Balloon kyphoplasty – single level | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 3.3 | Paraspinal injections | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E0340 | Closure of perforation of septum of nose | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.2 | Cranium | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4280 | Intracranial infection: burr hole | Intermediate | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3580 | Nipple areola complex reconstruction +/- liposuction and fat transfer | Major | £600.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P0320 | Marsupialisation of Bartholin cyst | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4910 | Percutaneous transluminal angioplasty of coronary artery(ies) with stent insertion | Complex | £1,100.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Complex | £1,000.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| W5701 | Excision arthroplasty of first metatarso-phalangeal joint with prosthetic implantation or interposition arthroplasty – bilateral | Xmajor | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H5940 | Excision of pilonidal sinus and suture/skin graft | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5700 | Distal pancreatectomy | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2580 | Ureterolysis ? bilateral | Xmajor | £700.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.2 | Mastectomy (excluding implant/reconstruction) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2710 | Radical mastectomy including block dissection | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7250 | Ileoanal anastomosis and creation of pouch | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9112 | Manipulation of joint (including intra-articular injection) for “Frozen Shoulder” (as sole procedure) | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5180 | Diagnostic bronchoscopy +/- biopsy | Minor | £320.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6810 | Neurolysis and transposition of peripheral nerve (excludes carpal tunnel release) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2989 | Mastectomy followed by immediate Deep Inferior Epigastric Flap (DIEP) reconstruction - unilateral | Complex | £3,000.00 | £1,559.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5220 | Retropubic suspension of neck of bladder (including colposuspension)(including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR370 | Embolisation of bronchial artery | Complex | £1,000.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 12.3 | Bladder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.3 | Burns, scars and contractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3322 | Laparoscopic abdominoperineal resection | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8751 | Local excision (multiple phlebectomy) of varicose vein(s) of leg - bilateral | Intermediate | £350.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.3 | Meninges | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4180 | Subdural haemorrhage – tap | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F3400 | Tonsillectomy - child (and bilateral) up to and including age 12 | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0603 | Primary excision of malignant lesion - trunk and limbs | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1540 | Exploration of entire middle ear course of VII | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A3300 | Implantation of neurostimulator to cranial nerve | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4543 | Open reduction, internal fixation and complete revision for peri-prosthetic fracture | Complex | £800.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2560 | Decompression for central spinal stenosis (one or two levels) | Xmajor | £900.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.8 | Spine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M4430 | Endoscopic removal of foreign body from bladder (including cystoscopy) | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 20142 | Insertion of implantable ECG loop recorder (including reporting) | £200.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.1 | Oesophagus | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2781 | Laparoscopic vagotomy/seromyotomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T5210 | Dupuytren’s fasciectomy multiple digits with proximal interphalangeal joints | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1680 | Parathyroid: re-operation | Xmajor | £750.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3013 | Mastectomy and immediate reconstruction of breast using fixed prosthesis - unilateral | Xmajor | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2002 | Laparoscopic repair of inguinal hernia - unilateral | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1780 | Diagnostic endoscopy of sinus and bilateral (as sole procedure) | Minor | £50.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.11 | Liver | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR610 | Transjugular intrahepatic portosystemic shunt | Complex | £900.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0330 | Pinnaplasty (including bilateral) (child 14 and below only) | Intermediate | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 5.8 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4510 | Fibreoptic examination of trachea including biopsy/removal of foreign body | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5533 | Percutaneous radiofrequency ablation of malignant neoplasm of lung | Complex | £1,900.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T3080 | Laparotomy and repair of multiple visceral trauma | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 17.4 | Embolisation | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR306 | Endovascular treatment of cerebral aneurysm | Xmajor | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0285 | Trapezio-metacarpal joint surface replacement | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4430 | Revision of total prosthetic replacement of ankle joint | Complex | £1,000.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5480 | Lung resection with resection of chest wall | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.3 | Meninges | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2210 | Drainage of subarachnoid space of brain | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J1820 | Cholecystectomy with exploration of common bile duct | Major | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25110 | Coeliac plexus block, splanchnic nerve block, hypogastric block - therapeutic +/- Image Guidance | Intermediate | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1580 | Excision of epididymal cyst | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.11 | Retina | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C8200 | Laser photocoagulation/cryotherapy of lesion of retina | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1012 | Excision of thyroglossal cyst/tract | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.3 | Trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4100 | Insertion of voice prosthesis (TOF) | Major | £500.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H2180 | Fibreoptic colonoscopy and recanalisation of tumour | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25160 | Trigeminal ganglion radiofrequency lesion (under X-ray control) | Intermediate | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H6020 | Laying open of pilonidal sinus | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K3210 | Closed mitral valvotomy | Complex | £1,300.00 | £1,071.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8723 | Selective dissection of cervical lymph nodes, levels 1 to 5 (+/- 6) | Complex | £800.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5280 | Revision retropubic suspension of neck of bladder (including colposuspension and cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 15.4 | Flaps and free skin grafts | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S3500 | Split autograft of skin, trunk and limbs – up to 25cm2 in area | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K4912 | Percutaneous transluminal angioplasty of coronary artery(ies) with stent insertion and intravascular ultrasound | Complex | £1,100.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7500 | Prosthetic open repair of ligament | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.10 | Knee | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W4280 | Total prosthetic replacement of knee joint – bilateral | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6020 | Resiting of Pacemaker or implantable cardioverter defibrillator (ICD) | Intermediate | £410.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E2920 | Horizontal supra-glottic laryngectomy | Complex | £1,000.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.4 | Other | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3593 | Microdochectomy or mammodochectomy (Hadfield’s procedure) | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25150 | Trigeminal ganglion injection (local anaesthetic under X-ray control) | Intermediate | £350.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.1 | Head and neck | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2930 | Bypass carotid artery from the arch | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9.7 | Varicose veins | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L8541 | Radiofrequency ablation of more than one venous trunk +/- phlebectomies - bilateral | Major | £600.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.6 | Mediastinum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.10 | Peritoneum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T4302 | Open adhesiolysis (including biopsy) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L6710 | Biopsy of artery (including temporal) (as sole procedure) | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.7 | Teeth | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F0830 | Replantation of natural tooth/teeth following trauma | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.7 | Other organs (mainly digestive) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2232 | Adrenalectomy - unilateral (open) | Major | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1410 | External frontoethmoidectomy and bilateral | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0751 | Laparoscopic subtotal hysterectomy (+/- oophorectomy) +/- ureterolysis | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2810 | Percutaneous replacement/implantation of pulmonary valve | Complex | £2,300.00 | £1,143.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3780 | Total prosthetic replacement of the hip, with or without cement, bilateral | Complex | £1,600.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8594 | Laparoscopic para-aortic lymph node dissection | Complex | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1900 | Operation(s) on varicocele | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S4212 | Debridement and primary suture of wound without involvement of deeper tissue (skin and subcutaneous fat only) - Head and Neck | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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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| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G2800 | Partial gastrectomy | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L3380 | Reinforcement of aneurysm of cerebral artery | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.8 | Spine | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.4 | Fibreoptic endoscopic procedures (GA or LA) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4510 | Fibreoptic examination of trachea including biopsy/removal of foreign body | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3520 | Microlaryngoscopy/laryngoscopy +/- biopsy, excision of lesion, polyp or cyst | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M2310 | Open ureterolithotomy (including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F3650 | Arrest of haemorrhage following tonsillectomy/adenoidectomy | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.3 | Trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4230 | Mini-tracheostomy (percutaneous) | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B3012 | Mastectomy and immediate reconstruction of breast using expandable prosthesis - unilateral | Xmajor | £550.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.1 | Connective tissue/tendon muscle | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7990 | Revision of open or arthroscopic rotator cuff repair +/- decompression | Major | £600.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0630 | Repair of pinna | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.5 | Mouth cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4040 | Suture of mouth as sole procedure | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L9350 | Basilic vein transposition | Major | £550.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.9 | Thyroid and parathyroid glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B1450 | Parathyroidectomy | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.2 | Middle ear and mastoid | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D1010 | Radical mastoidectomy (including meatoplasty) | Major | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0460 | Complex procedure to mid foot or hind foot without autogenous bone graft (osteotomy/fusion +/? tendon transfers) | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0930 | Closed reduction of fracture of zygomatic complex of bones | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4630 | Perforating graft (keratoplasty) to cornea | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A1240 | Creation of ventriculoperitoneal shunt | Major | £560.00 | £311.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1100 | Correction of hydrocele(s) – unilateral | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1649 | Complex pelvic osteotomies and fixation, eg triple osteotomy, peri-acetabular osteotomy | Complex | £1,000.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G1460 | Endoscopic mucosal resection of high-grade dysplasia in Barrett's oesophagus | Major | £440.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11.2 | Stomach | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4030 | Pyloroplasty | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0340 | Punch biopsy of cervix uteri | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4340 | Subconjunctival injection | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.8 | Other procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| X3750 | Botulinum toxin injections to muscle | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2620 | Membranous labyrinthectomy | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.5 | Mouth cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K3580 | Trans catheter aortic valve implantation (TAVI) without percutaneous insertion of a cerebral protection device | Complex | £2,300.00 | £1,143.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T7910 | Open sub acromial decompression and rotator cuff repair +/- excision of distal clavicle | Major | £650.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2020 | Prosthetic replacement of temporomandibular joint | Xmajor | £650.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L1810 | Repair of leaking aneurysm of ascending aorta | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8050 | Surgical release of humeral epicondylitis (lateral or medial) (eg “Tennis Elbow”) | Intermediate | £350.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7081 | Percutaneous posterior tibial nerve stimulation (PTNS) for overactive bladder (OAB) syndrome or faecal incontinence | Minor | £200.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G7512 | Revision of ileostomy - local | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W9020 | Dynamic arthrogram of joint | Intermediate | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1240 | Vidian neurectomy (including endoscopic) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0220 | Nephroureterectomy - unilateral | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0920 | Oesophagocardiomyotomy (Heller's operation) | Major | £550.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3400 | Cordectomy (endoscopic) | Intermediate | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W6703 | Secondary open reduction of dislocation of large joint | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2280 | Percutaneous occlusion of left atrial appendage | Xmajor | £800.00 | £974.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6462 | Excision or partial excision of IP joint of lesser toe with tendon transfer | Intermediate | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V2200 | Posterior decompression +/- foraminotomy - cervical region (1 or 2 levels) | Complex | £1,200.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.3 | Fractures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1642 | Open reduction/internal fixation of posterior rim of acetabulum | Complex | £1,000.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W0322 | Osteotomy/ies (eg Scarf and Akin) for Hallux Valgus correction with or without internal fixation and soft tissue correction - bilateral | Xmajor | £800.00 | £454.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5820 | Dilatation of outlet of female bladder (with cystoscopy) | Minor | £200.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q1700 | Therapeutic hysteroscopic operations on uterus (including endometrial ablation excluding microwave or radiofrequency ablation) +/- Mirena coil insertion | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1100 | Diagnostic thoracoscopy (+/- biopsy) | Minor | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR190 | CT/MRI guided drainage of fluid collection | Major | £450.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2302 | Coarctation repair | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.1 | Excision/biopsy codes | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T9000 | Sentinel node mapping and sampling with blue dye or radioactive probe for breast cancer | Intermediate | £500.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.6 | Non-specific | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR916 | Surgical removal of cuffed central venous catheter - tunnelled (X-ray guided) | Minor | £250.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E5410 | Pneumonectomy | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N0500 | Bilateral excision of testes | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3944 | Acetabular liner and head changes | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.3 | Renal vessels | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L4190 | Reconstruction of renal artery(ies) | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.5 | Sympathetic nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7683 | Presacral sympathectomy - therapeutic | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V0980 | Open reduction of fracture of zygomatic complex of bones | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.7 | Larynx and trachea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E3010 | Glottoplasty (e.g.vocal pitch change surgery) | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22003 | Sleep Electroencephalography (EEG) | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7100 | Extracapsular cataract extraction without implant - bilateral | Xmajor | £700.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.3 | Cervix uteri | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| Q0220 | Laser destruction of lesion of cervix uteri (+/- colposcopy or polypectomy) | Minor | £200.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Vascular system | |||||||||||||||||||||||||||||||||||||||||||||||||
| 9.8 | Lymphatic system | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T8550 | Block dissection of inguinal lymph nodes | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4610 | Transoral Incisionless Fundoplication (TIF) | Major | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0608 | Sentinel lymph node biopsy for melanoma | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C5300 | Excision of lesion of sclera | Intermediate | £200.00 | £259.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2080 | Primary repair of strangulated inguinal hernia | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A2600 | Other intracranial destruction of cranial nerve | Complex | £1,600.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.2 | Spinal cord | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4860 | Implantation/removal of epidural delivery system | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L2560 | Percutaneous or open placement of intra-aortic balloon (including subsequent removal) | Intermediate | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T2400 | Repair of umbilical/paraumbilical hernia (irrespective of age) | Intermediate | £300.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 | Simple procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 25000 | Incision and drainage (not elsewhere covered) | £75.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.4 | Muscles | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3530 | Surgical correction of squint with adjustable sutures | Xmajor | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes when 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T1030 | VATS pleurodesis/pleurectomy | Major | £700.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8780 | Diagnostic arthroscopic examination of joint, with or without biopsy - bilateral (not otherwise specified) (as sole procedure) | Intermediate | £400.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0342 | Boney meatoplasty | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C0213 | Excision of lesion of orbit - lateral orbitomy | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 4.8 | Iris and anterior chamber | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6130 | Goniotomy (surgical treatment of glaucoma) (including topical or local anaesthetic) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| N1352 | Laparoscopy for impalpable testis | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V5484 | Interspinous dynamic stabilisation procedure | Xmajor | £700.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3713 | Complex primary total hip replacement including bone grafting or femoral osteotomy | Xmajor | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.11 | Foot | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| T6720 | Tendo Achilles lengthening percutaneous | Intermediate | £350.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1220 | Caldwell-Luc procedure | Intermediate | £300.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6510 | Carpal tunnel release (open) | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M1360 | Percutaneous insertion of nephrostomy tube | Intermediate | £400.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1080 | Osteotomy of long bone, with/without fixation, including graft | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D2610 | Operation(s) on endolymphatic sac | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3943 | Removal of total hip replacement and complete clearance of cement | Complex | £1,600.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5220 | Retropubic suspension of neck of bladder (including colposuspension)(including cystoscopy) | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V4980 | Excision of intramedullary tumour | Complex | £1,300.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| S0633 | Excision of lesion of skin or subcutaneous tissue - up to three, Trunk & Limbs (excluding lipoma) | Minor | £175.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M5630 | Therapeutic injection into bladder neck for treatment of stress incontinence (periurethral bulking agents), including cystoscopy | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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. |
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| 10.1 | Endoscopic gastrointestinal procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G4520 | Diagnostic enteroscopy | Intermediate | £150.00 | £142.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| M0280 | Laparoscopic nephrectomy | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6580 | Carpal tunnel release (open) - bilateral | Intermediate | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 3.9 | Neurophysiological procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 22002 | Routine electroencephalography (EEG) in child under 5 (including reporting) | Minor | £100.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1450 | Bone flap to frontal sinus (and bilateral) | Major | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W1912 | Pinning of head of femur – open or percutaneous (eg slipped femoral epiphysis, undisplaced neck fracture) | Major | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, hip, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Consultations, Practitioner Fees, Simple Investigations and Procedures and General Procedures | |||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 | General procedures | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0702 | Aural toilet (including microsuction and/or suction of exteriorised mastoid cavity) including bilateral | £50.00 | £0.00 | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.9 | Lens | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C7124 | Phacoemulsification of cataracts, without lens implant - bilateral (including topical or local anaesthetic) | Major | £525.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.1 | Brain | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A0280 | Awake craniotomy with ablation of lesion of brain with or without cortical mapping/stereotaxy | Complex | £2,000.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4810 | Removal of superficial corneal foreign body | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.4 | Palate | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G0920 | Oesophagocardiomyotomy (Heller's operation) | Major | £550.00 | £428.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.5 | Bronchi/lungs/pleura | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E4600 | Sleeve resection of bronchus or pulmonary artery with pulmonary resection | Complex | £1,600.00 | £642.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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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| 8.7 | Video assisted thoracic surgery (VATS) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A7561 | VATS sympathectomy - bilateral | Xmajor | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| V3120 | Transthoracic/antero-lateral excision of intervertebral disc +/? fusion Including Spinal Cord Monitoring | Complex | £1,300.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2100 | Reconstruction of vagina | Xmajor | £750.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| D0820 | Reconstruction of external auditory canal | Xmajor | £850.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 14.4 | Vagina/perineum | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P1400 | Incision of introitus of vagina | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 5.4 | Nose and nasal cavity | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| L0230 | VATS closure of patent ductus arteriosus | Complex | £1,000.00 | £857.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7484 | Multiple ligament reconstruction | Xmajor | £700.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2700 | Replacement of tricuspid valve (including valvuloplasty) | Complex | £1,900.00 | £1,429.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W8680 | Therapeutic arthroscopy operation on cavity of joint - bilateral (not otherwise specified) (as sole procedure) | Complex | £800.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 2.3 | Meninges | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A4010 | Evacuation of extradural haematoma | Complex | £1,000.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.7 | Shoulder | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W7713 | Primary stabilisation of multi-directional instability of shoulder joint +/- tendon repair | Major | £550.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16.9 | Hip, leg and pelvis | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| W3942 | Removal of total hip replacement and creating a pseudarthrosis | Xmajor | £750.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 6.6 | Salivary glands | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F4600 | Incisional drainage of abscess or haematoma of salivary glands (ie including submandibular, parotid and sublingual glands) | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 4.1 | Globe and orbit | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 4.6 | Cornea | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C4730 | Removal of corneal suture | Minor | £100.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H0310 | Drainage of abscess of appendix or drainage of intra-abdominal abscess | Major | £450.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| F3440 | Tonsillectomy - adult, age 13 + (and bilateral) | Intermediate | £400.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| G3400 | Gastrostomy | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Thorax and intra-thoracic organs | |||||||||||||||||||||||||||||||||||||||||||||||||
| It is common practice with a number of intra-thoracic procedures to perform a rigid bronchoscopy. This
should not be separately itemised for billing purposes 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K2800 | Replacement of pulmonary valve (including valvuloplasty/valvotomy) | Complex | £1,900.00 | £1,285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 8.9 | Heart – cardiology | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| K6000 | Cardiac pacemaker system introduced through vein (single chamber) | Major | £450.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P2932 | Examination of vagina under anaesthetic as sole procedure | Minor | £100.00 | £129.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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) | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| J5520 | Total pancreatectomy | Complex | £1,300.00 | £714.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Breast | |||||||||||||||||||||||||||||||||||||||||||||||||
| 7.3 | Reconstruction | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| B2913 | Reconstruction of breast using latissimus dorsi including implantation of prosthesis (including delayed reconstruction) | Xmajor | £800.00 | £571.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Bones, joints and connective tissue/tendon muscle | |||||||||||||||||||||||||||||||||||||||||||||||||
| When a procedure code includes the narrative ‘including arthroscopic’, the majority of specialists do not
make additional charges for either a diagnostic or a therapeutic arthroscopy and we do not consider these to be additional procedures (except in unusual circumstances). We consider that decompression in the subacromial region which is frequently performed arthroscopically is covered by the code for subacromial decompression. This includes EUA, arthroscopy, and decompression of the subacromial region, excision of distal clavicle, reconstruction of acromioclavicular joint, acromioplasty and repair of a small rotator cuff tear. We will not routinely reimburse this as a multiple procedure although we will allow flexibility in individual cases. In such cases, we ask that sufficient clinical detail is provided to allow assessment by an orthopaedic consultant. Knee arthroscopy. At most knee procedures, in addition to the main procedure, a number of lesser procedures are frequently performed such as excision of sinovium, drilling of cartilage, removal of loose bodies, excision of plica lateral release etc. The code W8500 should be used in isolation for multiple arthroscopic procedures. EUA/MUA/Injection into joint. With all arthroscopies we consider that EUA/MUA and injection into joint are part of the procedure. The only circumstances we would reimburse as a multiple is where the injection is into a different joint and we ask that this is made clear on the invoice. Application of plaster of Paris is part of any procedure where immobilisation is routine – e.g. fracture reduction, tendon repairs and various osteotomies. As a rule we will not reimburse extra charges for this procedure. Where a procedure usually or frequently necessitates bone grafting, additional charges should not be made for this as a separate service. There is a significant number of other areas where in our opinion orthopaedic procedures have been unreasonably disaggregated in the past. This particularly applies to shoulder procedures. Procedures on the distal clavicle, acromioclavicular joint, glenohumeral arthroscopy, bursas and rotator cuff repair should not be added to subacromial decompression. Please note that all procedure codes and descriptions include the application of the first cast. For subsequent, additional application of cast use code in Fractures section (16.3). Please also note that all procedure codes in the fixation/arthrodesis section have been moved to individual areas. The following definitions are used throughout this section: Long bones – clavicle, fibula, humerus, radius, scapula, tibia and ulna Small bones – all bones of hand, wrist, foot, ankle and also the patella Large joints – ankle, elbow, 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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| 16.4 | Nerves | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| A6900 | Revision of release of peripheral nerve | Major | £450.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C3960 | Excision of pterygium | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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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| 17.3 | Angioplasty | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR430 | Renal angioplasty, +/- insertion of stent | Major | £500.00 | £285.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| C6930 | Injection into anterior chamber (including topical or local anaesthetic) | Minor | £150.00 | £194.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1500 | Operation(s) on sphenoid sinus (including endoscopic) and bilateral | Intermediate | £250.00 | £213.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Abdomen (excluding urinary and reproductive organs) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Many pathological processes eg cholecystitis result in the formation of adhesions. Adhesiolysis is
therefore part of these procedures. We no longer have a specific code for division of adhesions. When major problems due to adhesions are 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| H3380 | Partial excision of rectum and sigmoid colon for prolapse | Xmajor | £750.00 | £499.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| XR935 | Insertion/removal of vena cava filter | Intermediate | £400.00 | £0.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| P0510 | Simple vulvectomy | Major | £600.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||
| 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 | Contracted Procedure Fee | Contracted Anaesthetist Fee | |||||||||||||||||||||||||||||||||||||||||||||||
| E1480 | Endoscopic exploration frontal sinus beyond frontoethmoid recess and bilateral | Xmajor | £650.00 | £357.00 | ||||||||||||||||||||||||||||||||||||||||||||||