Surface Pathology

Trauma Scars

a. Neck or Face 

• Includes non-hair bearing areas of the scalp. 

• Repair of all significant and unsightly such scars, including acne scars, is a benefit of MSP. 

• Repair procedures will depend upon the lesion but may include excision, revision, dermabrasion, etc. Rhytidectomy procedures to remove scar prominence, however, are not a benefit of MSP. 

• Implantation of collagen, etc. to restore contour, or chemical abrasion to reduce hyperpigmentation are not benefits of MSP except in those rare cases where the pitting or the pigmentation is so severe that a generally acceptable result would not be possible without these procedures. 

• MSP authorization for repair of such scars is required.

b. Scars in other Anatomical Areas

• Repair of scars which interfere with function or which are significantly symptomatic (pain, local irritation, etc.) is a benefit of MSP.

• Scars with no significant symptoms or functional interference: 

(i) Repair is a benefit if such repair is carried out within a reasonable period of convalescence, or is part of a pre-planned post-traumatic (including post surgical) staged process. MSP notification must be included as part of the planning process in the latter case. 

(ii) Other post-traumatic scar revision is not a benefit of MSP. 

(iii) Revision of acne scars other than on the face or neck is not a benefit of MSP. 

• MSP authorization is required for all scar repair procedures

Keloids and Hypertrophic Scars

a. Head or Neck 

• The repair of all significant and unsightly scars, such as keloids, is a benefit of MSP. 

• Repair procedures may include excision and/or injection. 

Surgery for Alteration of Appearance

a. Surgery to alleviate significant physical symptoms or to restore or improve function to any area altered by disease, trauma or congenital deformity normally is a benefit under MSP. Surgery solely to alter or restore appearance is not a benefit of MSP except under the circumstances listed in the following policy. 

b. In establishing this policy, it has been recognized that:

 • peer acceptance in our society often is influenced disproportionately by the face, 

 • children are especially susceptible to emotional trauma caused by physical appearances,

• some procedures traditionally have been accepted as benefits of Health Insurance Plans in spite of the obvious cosmetic nature of these procedures. 

c. Emotional, psychological or psychiatric grounds are not considered sufficient reason for MSP coverage of surgery for alteration of appearance except in children and under exceptional circumstances in adults. 

On request of the attending medical practitioner, exceptions may be made on an independent consideration basis if the proposed surgery is to alter a significant defect in appearance caused by disease, trauma or congenital deformity, and if the surgery is essential to obtain employment as documented by the attending physician and by an employer with regard to a specific job. 

d. Surgery to revise or remove features of physical appearance which are familial in nature is not a benefit of MSP. 

e. Within the context of this policy, the word "disease" does not include the normal sequelae of aging. Surgery to alter changes in appearance caused by aging is not a benefit of MSP. 

f. Within the context of this policy, the word "trauma" includes trauma due to treatment such as surgery, radiation, etc.

 g. As the phrase “reasonable period of convalescence” is imprecise, independent consideration will be given to more complex cases or extenuating circumstances. 

Diagnostic and Selected Therapeutic Procedures

 The listings under the “Diagnostic Procedures and Selected Therapeutic Procedures” section of the MSC Payment Schedule may be claimed in addition to a consultation or other assessment/visit, when performed during that visit. If, however, the procedure takes place on a subsequent visit arranged to perform the procedure, then that visit may not be claimed in addition to the procedure unless the fee code for the latter is prefixed by the letter “Y”. A subsequent visit fee will be paid in addition to the procedure if more than thirty (30) days has elapsed between the initial visit or service and the diagnostic procedure. 

b. Diagnostic procedures may be claimed in addition to surgical procedures, when applicable. 

c. For multiple diagnostic procedures performed at the same sitting, the procedure having the largest fee may be claimed in full and the remaining procedure(s) at 50 percent of the listed fee(s), unless otherwise specifically indicated in the Payment Schedule.

d. When two diagnostic/therapeutic procedures are performed by separate medical practitioners at the same sitting and both procedures are or should be within the competence of either medical practitioner, the total fee claimed should be no greater than that which would be payable if both procedures had been performed by one medical practitioner, plus one assistant’s fee (if applicable). 

e. When a medical practitioner performs a diagnostic procedure, s/he must be allowed to appropriately perform a full or limited consultation for which s/he charges and is paid, regardless of what consultations and procedures have been performed by other specialists or sub-specialists. The consultation would require a written report in addition to the report of the diagnostic procedure. 

If the diagnostic procedure is done on an initial visit, and the initial visit is for the specific purpose of performing the diagnostic procedure, and this visit occurs on an out-patient basis in a procedure facility (including endoscopy suites and cardiac catheterization suites), then a limited consultation would normally be billed rather than a full consultation. 

f. Procedures designated as “extra” will be paid at 100 percent for the first “extra” and 50 percent for any additional procedures designated as “extra”. Should all procedures be designated as “extra” then the first procedure will be deemed a regular procedure and payment for the first subsequent “extra” will be at 100 percent and all others at 50 percent.

Minor Diagnostic and Therapeutic Procedures

a. Minor Diagnostic and Therapeutic Procedures are defined as procedures which have a fee value that is less than that of the office visit. . Note: To determine the service with the greatest value when a tray fee is applicable, the amount of the tray fee will be added to the value of the procedure fee in the calculation process. 

b. When minor diagnostic or therapeutic procedures are performed in conjunction with an assessment/visit (not a consultation) either the visit or the procedure may be claimed, but not both. Includes fee items identified as “isolated procedures”. 

Surgical Assist

i) Time, for the purposes of fee codes 00193, 00195, 00196, 00197, 00198, 07920, T70019 and T70020 is calculated at the earliest from the when the medical surgical assistant makes contact with the patient in the operating suite. The end time is defined as when the assistant leaves the operating suite. 

ii) Where a medical practitioner renders surgical assistance at two operations under the same anesthetic but for which repositioning or redraping of the patient or more than one separately draped surgical operating field is medically/surgically required, separate assistants’ fees may be claimed for each operation, except for bilateral procedures, procedures within the same body cavity, or procedures on the same limb. 

iii) If, in the interest of the patient, the referring medical practitioner is requested by the patient or the surgeon to attend but does not assist at the procedure, attendance at surgery may be claimed as a subsequent hospital visit. 

iv) The specialist’s assistant listings apply only to surgical procedures having unusual technical difficulties identified and documented by the primary surgeon in a detailed note record as necessitating the services of a certified surgical assistant. The general assistant listings are applicable to all other situations where surgical assistance is necessary. (Also see Preamble B. Definitions, Prefixes to Fee Codes). 

v) Where surgery is abandoned, independent consideration will be given to the fee applicable to the assistant, to a maximum of 50 percent of the listed assistant fee for the intended procedure.

Cosmetic Surgery 

The guidelines for MSP coverage of surgery for alteration of appearance are listed under Preamble D. 9. For cosmetic surgery not covered by MSP, the anesthetic and assistants’ fees also are not covered. In addition, hospitalization charges are not insured for cosmetic surgical procedures not covered by MSP.

Fractures and Other Trauma 

a. When multiple procedures for multiple fractures and/or soft tissue injuries are done by the same surgeon, through different incisions, the largest fee should be charged at 100% and all subsequent fees at 75%. In cases of dissociated injuries for which the presence of one impedes the progress of another, or in the case of multiple major fractures (e.g.: a fractured femur and tibia in the same limb), a full fee for each (to a maximum of 3) may be charged provided that adequate clinical evidence to support this charge is rendered with the account.

 b. Open (compound) fractures: primary wound management fee(s) may be charged in addition to the fracture fee and will be paid at the same percentage as applies to the fracture fees. These wound management fee items are exempt from the 14 day rule (D.5.1). Secondary wound management fees may also be charged and are exempt from the 14 day rule (D.5.1). These primary and secondary Wound Management fees are only applicable where fee items have been designated in a section’s schedule of fees for specific open fractures or specified primary or secondary wound management of fractures.

 c. Open reduction of fracture or dislocation when necessary - 50% extra may be charged if a fee for open reduction is not listed. 

Surgery

General 

The fees for surgery, unless otherwise specifically indicated, include the surgical procedure itself and in-hospital post-operative follow-up, including removal of sutures and care of the operative wound by the surgeon or associate. Unless otherwise specifically indicated, the normal post-operative period included in the surgical fee is 14 days and the surgery fees include all concomitant services necessary to perform the listed service (including preparation of the operative site, incision, exploration, review of the results of diagnostic services rendered during the surgery, closure, and pre and post-operative discussion with the patient and/or patient’s family). 

When unusual circumstances require that additional medical services are provided in the in-hospital 14 days following a surgical procedure over and above the concomitant services necessary to perform the operative procedure, the additional services performed are not part of the inclusive fee for the surgical procedure and may be billed separately. A note record is required.

Operation Only 

For listings designated “operation only” the in-hospital, 14 day post-operative visits may be claimed in addition to the surgical procedure, with the exception of the visit(s) made on the day of the procedure.

Multiple Surgical Procedures 

i) When two or more similar procedures (including bilateral procedures) are performed under the same anesthetic, or when two or more procedures are performed in the same general area, whether through the same incision, an extension of that incision or through separate incisions, the procedure with the greater listed fee may be claimed in full and the fees for the additional procedure are reduced to 50 percent, unless otherwise indicated by the Schedule. However, additional incidental surgery performed en passant (i.e. surgery which would not have been performed in the absence of the primary procedure, such as an appendectomy during abdominal surgery, or incidental cystectomy during gynecological surgery) is considered to be included in the fee for the planned procedure and may not be charged. 

ii) When two or more different procedures are performed through separate incisions under the same anesthetic, and repositioning or redraping of the patient or more than one separately draped surgical operating field is medically/surgically required (because of the nature of the procedure and/or the safety of the patient), the procedure with the greater listed fee may be claimed in full and the fees for the additional such procedures are reduced to 75 percent, unless otherwise indicated by the Payment Schedule.

iii) Procedures which are listed as “extra” in the Payment Schedule may be claimed at the full listed fee even when performed with other surgical procedures, unless otherwise indicated in the Payment Schedule. 

iv) When two procedures are performed under the same anesthetic by two surgeons and both procedures are or should be within the competence of either one of the operators within the specialty or specialities, the total surgical fee claimed should be no more than that which would be payable if both procedures had been performed by one surgeon, plus one assistant’s fee. 

v) Except where team fees are specifically listed in the Payment Schedule or where a team fee reasonably could be expected to apply, when two procedures are performed under the same anesthetic by two surgeons whose different specialty skills are required to perform both procedures, each surgeon may claim his/her specific services as if they were performed in isolation from the other surgeon. These surgeons are not eligible for assistant fees for assisting each other, however, unless each of the surgical procedures takes place consecutively instead of concurrently. 

. Long-Term-Care Institution Visits

When visits are required to patients in long-term-care institutions (such as nursing homes, intermediate care facilities, extended care units, rehabilitation facilities, chronic care facilities, convalescent care facilities and personal care facilities, whether or not any of these facilities are situated on the campus of an acute care facility) claims may be made to a maximum of one visit every two weeks. It is not sufficient, however, for the medical practitioner simply to review the patient’s chart. A face-to-face patient/medical practitioner encounter must be made. For acute concurrent illnesses or exacerbation of original illness requiring institutional visits beyond the foregoing limitations, additional institutional visits may be claimed with accompanying written explanation.

Palliative Care 

The Palliative Care listings are applicable to the visits for palliative care rendered to terminally ill patients suffering from malignant disease or AIDS, or end-stage respiratory, cardiac, liver and renal disease and end-stage dementia with life expectancy of up to 6 months. These listings only apply where aggressive treatment of the underlying disease process is no longer taking place and care is directed instead to maintaining the comfort of the patient until death occurs.

 Claims for these listings should be billed continuously from time of determination of patient’s palliative status, for a period not to exceed 180 days prior to death. Under extenuating circumstances palliative listings billed beyond 180 days will be given independent consideration upon receipt of an explanatory note record. 

The listings are applicable to patients in acute care hospitals, hospice facilities or other institutions whether or not the patient is in a designated palliative care unit. The palliative care listings do not apply when unexpected death occurs after long hospitalization for a diagnosis unrelated to the cause of death.

Sub Acute Care 

Sub acute care is payable twice per week under fee items 00108, 13008. If more services or concurrent care is required an explanatory note record should accompany the claim submission. Independent consideration will be given to these claims.

Emergency Department Examinations 

Emergency department examinations are designated by various intensity levels of emergency department care. These fee codes apply only to those circumstances where either specialists in emergency medicine or other medical practitioners are physically and continuously present in the Emergency Department or its environs for an arranged designated period of time. For complete details, please refer to the Emergency Medicine section of the MSC Payment Schedule.

House Calls 

i) A house call is considered necessary and may be billed only when the patient cannot practically attend a physician’s office due to a significant medical or physical disability or debility and the patient’s complaint indicates a serious or potentially serious medical problem that requires a medical practitioner’s attendance in order to determine appropriate management;

 ii) A house call may be initiated by the patient, the patient’s advocate, or the physician when planned proactive care is determined to be medically necessary to manage the patient’s condition;

iii) If a house call is determined to be necessary and is rendered any day of the week between 0800 and 2300 hours, the house call should be billed as a home visit (use 00103); 

Surgery by a Visiting Doctor

If a surgeon operates outside of his/her geographical area, (for example as part of an outreach program or other such circumstances), and because of this, s/he is unable to render the usual postoperative care, the medical practitioner who performs this service for the patient may claim for necessary hospital visits at the usual frequency, as described under Preamble D.4.2. Claims for such post-operative care should be accompanied by a written explanation or an electronic note record. No such claims, however, should be made if the hospital at which the post-operative care is being rendered is within the same metropolitan area or within 32 km of the surgeon’s home or office.

Long-Stay Hospitalization 

For long stays in an acute care hospital including discharge planning and holding units because of serious illness extending beyond 30 days, claims for subsequent hospital visits greater than two visits per patient per week should include an explanation, and will be given independent consideration. 

Directive Care 

Directive care refers to those subsequent hospital visits rendered by a consultant in cases in which the responsibility for the case remains in the hands of the attending practitioner but for which a consultant is requested by the referring physician to give directive care in hospital during the acute phase. Payments for directive care are limited to two visits per patient per week (Sunday to Saturday), even when there is no interval between visits, for each consultant requested to render directive care by the referring practitioner.

Concurrent Care 

For those medical cases where the medical indications are of such complexity that the concurrent services of more than one medical practitioner are required for the adequate care of a patient, subsequent visits should be claimed by each medical practitioner as required for that care. To facilitate payment, claims should be accompanied by an electronic note record, and independent consideration will be given. For patients in I.C.U. or C.C.U. this information in itself is sufficient