Governing Rule: 6.8

MAJOR PROCEDURES

6.8.1
HSCs with a designated category code of 1 and 15 include related post-operative services and those with a designated category code of 3, 4, 6 and 14 include both related pre-operative and post-operative services.
1. a consultation benefit may be claimed up to and including the day of surgery.
2. pre-operative hospital care may be claimed by the physician who performs the surgery if information is submitted to show that conservative treatment was attempted before surgery was performed.
3. benefits may be claimed as applicable for complications occurring during or following post-operative time periods.
4. Deleted
5. HSC 03.04R may be claimed in the pre-operative time frame when all conditions in the notes have been met.
The following chart gives the pre-operative and post-operative periods.
Category Pre-operative Post-operative
1 0 - Days 14 - Days
3 7 - Days 7 - Days
4 7 - Days 14 - Days
6 14 - Days 14 - Days
14 30 - Days 14 - Days
15 0 - Days 7 - Days
AMA billing tips:
- Consultations may only be claimed when ALL of the following criteria have been met:
  - Patient is examined by referring provider (full list G.R. 4.4.1)
  - Referring provider specifically requests (verbal or written)opinion and or advice of consultant
  - Consultant performs:
  1. full history and
  2. full physical (relative to their specialty)
  3. may order lab or diagnostics.
  4. discusses treatment and advice with the patient and in some cases the referring provider
  5. provides referring provider with written report about recommendations, treatment, opinion.
  Consultations may NOT be claimed for transfer of care or pre operative assessments.
  Consultations are billable up to and including the day of surgery.
  Read more
6.8.2
Deleted
6.8.3 Deleted
1. Deleted
2. Deleted

6.8.4

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

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

GR 6.8.4 applies to the following HSCs:

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

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

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

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

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

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

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

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

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

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

AMA billing tips:
- The UGA (Under General Anesthetic) modifier is intended to compensate physicians for the inconvenience of scrubbing in and preparing to do a procedure in the OR with the patient Under General Anesthetic when the procedure is ordinarily performed in a standard room without general anesthetic. Criteria:
  • The UGA modifier is attached to procedures that may require an anesthetic and are paid less than the UGA modifier.
  • It can be applied to a procedure when the conditions are such that the patient would not tolerate the procedure without the use of a general anesthetic and the physician must complete the service in the OR with the use of general anaesthetic.
  • The UGA modifier does not apply to second and subsequent procedures done under the same anesthetic at the same operative encounter. Multiple procedures: The UGA modifier can be applied if more than one procedure is provided at the same encounter and only when each procedure is paid less than the rate of the UGA modifier. The physician may submit the UGA modifier on the procedure with the greater benefit rate. All other services provided at the same encounter will be paid at the rates listed in the Price List. All other payment modifiers will be applied as appropriate, e.g., LVP75, ADD, LVP50, etc.
  When one or more of the procedures provided in the OR and under general anesthetic is paid equal or greater than the rate for the UGA modifier, the UGA modifier does not apply. It cannot be added to the service. The rates for each procedure will be applied according to the Price List.
  For more information, please review Governing Rule 6.8.4
6.8.5
GR 6.8.4 does not apply to surgical assistance or anesthetic benefits.
6.8.6
If a surgeon does not provide the major portion of the post-operative care, the surgical benefit may be reduced to a lesser rate than listed for the procedure.
6.8.7
The physician providing the post-operative care under GR 6.8.6 may submit claims on a fee for service basis.
6.8.8
For those unusual situations where surgery is performed by a travelling surgeon (in accordance with the policy of the CPSA ) the full benefit for the procedure may be claimed. If another physician participates in post-operative care his/her services may be claimed on a fee for service basis.

91.01H	91.01J	91.02A	91.03A	91.03B	91.05E
91.05H	91.06D	91.06E	91.07A	91.08B	91.70A
91.70B	91.71	91.73A	91.73B	91.77B	91.77C
91.78A	91.78B	92.70	92.71	92.72	92.74
92.75	92.76	92.78C	93.91A	93.91B	94.04
95.02A	95.03	95.81A	95.93	95.96A

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Governing Rules

Governing Rule: 6.8

MAJOR PROCEDURES

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AMA billing tips:

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

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Governing Rules

Governing Rule: 6.8

MAJOR PROCEDURES

AMA billing tips:

AMA billing tips:

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