S.I. No. 83/1996 - Health Insurance Act, 1994 (Minimum Benefit) Regulations, 1996


S.I. No. 83 of 1996.

HEALTH INSURANCE ACT, 1994 (MINIMUM BENEFIT) REGULATIONS, 1996

The Minister for Health in exercise of the powers conferred on him by sections 3 and 10 of the Health Insurance Act, 1994 (No. 16 of 1994) hereby makes the following Regulations—

PART 1 GENERAL

1. These Regulations may be cited as the Health Insurance Act, 1994 (Minimum Benefit) Regulations, 1996.

2. These Regulations shall come into operation on the 28th day of March, 1996.

3. In these Regulations—

"appropriate health services" means health services in relation to the diagnosis or treatment of the illness or injury of a patient which would be accepted generally by the medical profession as appropriate and necessary having regard to good standards of medical practice and to the nature and cost of any alternative forms of treatment as well as to all of the circumstances relevant to the patient;

"benefit year" means a period of a year from—

(a) the commencement of a health insurance contract, or

(b) the anniversary of the commencement of a health insurance contract;

"day-patient day" means a day, including a day upon which an inpatient stay commences and ceases, during the course of which a fully insured person is maintained in private hospital accommodation for the purpose of receiving day-patient services;

"day-patient services" means health services provided in, or by persons attached to, a hospital where the patient is admitted on an elective basis for care and/or treatment which does not require the use of a hospital bed overnight and is discharged as scheduled;

"dependent person" has the meaning assigned to it by section 1 of the Health (Nursing Homes) Act, 1990 ;

"excess" means an amount by which in specified circumstances a payment shall be reduced provided that such amount shall never be greater than the payment before any such reduction;

"fully insured person" means an insured person named in a health insurance contract other than a contract which relates solely to one or both of the following—

(a) ancillary health services; or

(b) public hospital daily in-patient charges made under Regulations pursuant to Section 53 of the Health Act, 1970 ;

"health services provider" means a publicly- funded hospital, private hospital, registered nursing home or hospital consultant, as appropriate;

"hospital consultant" means a registered medical practitioner who holds a current full registration with the Irish Medical Council and is engaged in hospital practice and who, by reason of his or her training, skill and experience in a designated speciality, is consulted by other registered medical practitioners and undertakes full clinical responsibility for patients in his or her care, or that aspect of care on which he or she has been consulted, without supervision in professional matters by any other person;

"initial waiting period" has the meaning assigned to it in the Health Insurance Act, 1994 (Open Enrolment) Regulations, 1996 ( S.I. No. 81 of 1996 );

"in-patient day" means a day during an in-patient stay where the day on which that stay ceased is deemed a whole day and the day on which that stay commenced is disregarded except that if that stay commenced and ceased on the same day then that day shall be deemed a day-patient day;

"in-patient services" means in-patient services within the meaning of the Health Act, 1970 , but excluding day-patient services;

"in-patient stay" means a continuous period during which a fully insured person is maintained in private hospital accommodation for the purpose of receiving in-patient services, such period—

(a) to commence on the later of the occurrence of the following events—

(i) the most recent admission or transfer of that person to private hospital accommodation; or

(ii) the cessation of the most recent previous in-patient stay in respect of that person; and

(b) to cease on the occurrence of the earlier of the following events—

(i) the next subsequent discharge or transfer of that person from private hospital accommodation;

(ii) the death of that person; or

(iii) a designation of the cessation of that period by the registered undertaking which effected the health insurance contract under which that person is named

provided that the effect of a designation under sub-paragraph (iii) shall not be to cause such a period to comprise less than five in-patient days or a day-patient day;

"insured person" means a person named in a health insurance contract as an insured person or an infant born to a person named in a health insurance contract provided that in the case of an infant the person who effected the health insurance contract requests that the health insurance contract be altered to name such infant as an insured person, and pays the appropriate premium in respect of such infant, within 13 weeks of the date of birth of the infant;

"nursing home" has the meaning assigned to it in section 2 of the Health (Nursing Homes) Act, 1990 ;

"pathological procedure" has the meaning assigned to it in Schedule C of these Regulations;

"pre-existing condition waiting period" has the meaning assigned to it in the Health Insurance Act, 1994 (Open Enrolment) Regulations, 1996 ( S.I. No. 81 of 1996 );

"prescribed health services" means—

(a) in-patient services

(b) day-patient services

(c) out-patient services

(d) health services provided by a hospital consultant whether in a hospital setting or otherwise which are appropriate health services and the sole purpose of which is the medical investigation, treatment, cure, or alleviation of the symptoms, of illness or injury but excluding—

(i) treatment directly or indirectly arising from or required in connection with male and female birth control, infertility and any form of assisted reproduction;

(ii) dental, orosurgical or orthodontic treatment or consultation with a dental practitioner, other than those services prescribed in Schedule C of these Regulations;

(iii) cosmetic services or treatment except the correction of accidental disfigurement or significant congenital disfigurement;

(iv) health services relating to eating disorders or weight reduction;

(v) preventive health services such as check-ups or screenings;

(vi) health services provided by a nursing home other than a registered nursing home;

(vii) nursing care, whether provided in an institution or otherwise, to persons who are dependent persons other than such care provided in the course or consequence of the provision of in-patient, day-patient or out-patient services;

(viii) health services received overseas;

(ix) health services provided other than

(I) as a result of the insured person having been referred to the health services provider by a registered medical practitioner; or

(II) in an emergency; or

(III) in connection with an obstetric condition;

(x) health services necessitated directly or indirectly by war or civil disturbance;

"prescribed minimum payment" means an amount determined in accordance with article 5 and shall not in any event exceed the amount of the fee or charge made in respect of the relevant prescribed health services;

"private hospital" means a hospital, other than a nursing home, which

(a) provides prescribed health services, and

(b) is not a publicly-funded hospital;

"private hospital accommodation" means accommodation in a private hospital or accommodation in a publicly- funded hospital which is designated by the Minister for Health as private or semi-private accommodation;

"private psychiatric hospital" means a facility registered pursuant to the Mental Treatment Act, 1945 ;

"publicly-funded hospital" means a hospital, other than a nursing home, which provides services to a person pursuant to his or her entitlements under Chapter II of Part IV of the Health Act, 1970 ;

"radiological procedure" has the meaning assigned to it in Schedule C of these Regulations;

"registered medical practitioner" means a person whose name appears in the General Register of Medical Practitioners maintained under the Medical Practitioners Acts, 1978 and 1993;

"registered nursing home" means a nursing home registered pursuant to the Health (Nursing Homes) Act, 1990 ;

"screening" means a medical examination or test that is not reasonably required for the management of the medical condition of the patient;

"single room" means a hospital bedroom designed for and accommodating only one patient;

"special procedures" mean the procedures which are listed in Schedule B of these Regulations;

"surgical procedure" has the meaning assigned to it in Schedule C of these Regulations;

"third party recovery" means a payment to a registered undertaking as a result of the acceptance by a third party of full or partial liability for fees or charges arising from the provision of prescribed health services to an insured person.

4. In these Regulations a reference to an article means a reference to an article of these Regulations and a reference to a subarticle means a reference to a subarticle in the article to which it is referred.

PART II PRESCRIBED MINIMUM PAYMENTS

5. (1) A health insurance contract effected by a registered undertaking (other than such a contract relating solely to ancillary health services and/or solely to the public hospital daily in-patient charges made under Regulations, pursuant to Section 53 of the Health Act, 1970 ) shall provide for the payment by that undertaking, in respect of the provision of prescribed health services to an insured person by a health services provider, of amounts that are not less than the amounts provided for in these Regulations (herein referred to as the "prescribed minimum payments").

(2) Prescribed minimum payments shall be determined in accordance with Schedule A (payments in respect of hospital charges (in-patient and day patient services)), Schedule B (payments in respect of hospital charges relating to special procedures), Schedule C (payments in respect of consultants' fees (in-patient and day-patient services)), or Schedule D (payments in respect of hospital charges and consultants' fees (out-patient services)), as appropriate and as amended from time to time.

(3) If all registered undertakings combined have been required to make prescribed minimum payments in relation to in-patient services provided to an insured person in respect of any psychiatric condition other than a condition described in subarticle (4) for a total of 100 in-patient days in a calendar year then notwithstanding the provisions of subarticles (1) and (2) a registered undertaking shall not be required to make any further such payments in respect of the same calendar year.

(4) If all registered undertakings combined have been required to make prescribed minimum payments in relation to in-patient services provided to an insured person constituting treatment for alcoholism, drug or other substance abuse for a total of 91 in-patient days in any continuous period of 5 years then notwithstanding the provisions of subarticles (1), (2) and (3) a registered undertaking shall not be required to make any further such payments in respect of that 5 year period.

(5) A registered undertaking shall not be required to make any prescribed minimum payments in respect of prescribed health services provided by a registered nursing home unless—

(i) such prescribed health services are provided to an insured person immediately following the provision of in-patient services to such insured person; and

(ii) the registered undertaking has received and approved, prior to the admission of the insured person to the registered nursing home, a certificate from the hospital consultant responsible for the treatment of the insured person, in such form as may be specified by the undertaking, to the effect that the prescribed health services to be provided by the registered nursing home are appropriate health services.

(6) If all registered undertakings combined have been required to make prescribed minimum payments in respect of in-patient and day patient services provided to an insured person for a total of 180 days (in-patient and day-patient days combined) in a calendar year then notwithstanding the provisions of subarticles (1), (2), (3) and (4), a registered undertaking shall not be required to make any further prescribed minimum payments in respect of in-patient or day-patient services provided to such insured person.

(7) This article applies subject to article 9.

PART III LIMITATION ON TYPE OF HEALTH SERVICES FOR WHICH PAYMENT MUST BE MADE

6. (1) A registered undertaking shall not be required to make the prescribed minimum payments specified in sub-paragraphs (1), (2), (3) or (6) of paragraph 1 of Schedule A in respect of in-patient services if, on receipt of appropriate medical advice, the undertaking determines that the health services provided to the insured person could have been provided as day-patient services or out-patient services rather than in-patient services. In such circumstances if the undertaking determines that—

( a ) the relevant health services should have been day-patient services, the prescribed minimum payments may be the amounts specified in sub-paragraphs (4) or (5) of paragraph 1 of Schedule A, as appropriate; or

( b ) the relevant health services should have been out-patient services and if the relevant health services were provided in a private hospital, the prescribed minimum payments may be the amounts specified in Tables D.1 and D.2 of Schedule D, as appropriate.

(2) A registered undertaking shall not be required to make the prescribed minimum payments specified in sub-paragraphs (4) or (5) of paragraph 1 of Schedule A in respect of day-patient services if, on receipt of appropriate medical advice, the undertaking determines that the health services provided to the insured person could have been provided as out-patient services rather than day-patient services. In such circumstances, and if the relevant health services were provided in a private hospital, the undertaking may make the prescribed minimum payments specified in Tables D.1 and D.2 of Schedule D.

(3) If the health services provided to an insured person were not prescribed health services, a registered undertaking shall not be required to make any payment.

(4) This article applies subject to article 9.

PART IV LIMITATIONS ON PRESCRIBED MINIMUM PAYMENTS IN RESPECT OF OUT-PATIENT SERVICES

7. Notwithstanding articles 5 and 6, the total amount which must be paid by a registered undertaking in respect of out-patient services listed in Table D.1 of Schedule D (and all in-patient services and day-patient services in respect of which the prescribed minimum payment is, in accordance with subarticle 1(b) or subarticle (2) of article 6, determined by reference to Table D.1 of Schedule D) provided to all insured persons named in a health insurance contract in a benefit year shall be the total of the prescribed minimum payments determined by reference to Table D.1 of Schedule D provided that in the case where the health insurance contract—

( a ) relates to only one insured person that total amount shall be subject to a maximum of £650 and shall also be subject to an excess of £150, and

( b ) relates to more than one insured person that total amount shall be subject to a maximum of £1,300 and shall also be subject to an excess of £300.

PART V HEALTH SERVICES PROVIDED DURING THE PRESCRIBED WAITING PERIODS

8. (1) Notwithstanding articles 5 and 6, a registered undertaking shall not be required to make a prescribed minimum payment in respect of prescribed health services provided to an insured person during the initial waiting period applicable to such a person, except where such prescribed health services are provided as a result of accident or injury to the insured person which occurred while that person was an insured person.

(2) Notwithstanding articles 5 and 6, a registered undertaking shall not be required to make a prescribed minimum payment in respect of prescribed health services provided to an insured person during a pre-existing condition waiting period except where such prescribed health services do not relate to the condition which gave rise to that waiting period.

PART VI HEALTH SERVICES PROVIDED BY A PARTICULAR HEALTH SERVICE PROVIDER

9. Where:

( a ) the provision of specified prescribed health services by a health service provider is not covered under the terms of a contract; and

( b ) the specified prescribed health services concerned could have been provided by a health service provider who is specified in that contract,

then notwithstanding articles 5 and 6, a registered undertaking shall not be required to make a prescribed minimum payment in respect of those prescribed health services.

PART VII MISCELLANEOUS PROVISIONS

10. Notwithstanding articles 5 and 6, the total amount of prescribed minimum benefits payable by a registered undertaking in respect of the provision of prescribed health services to an insured person may be reduced by any corresponding third party recoveries which that registered undertaking has made in respect of those services.

11. The prescribed minimum benefit which a registered undertaking is required to make under sub-paragraphs (3), (5) and (6) of paragraph 1 of Schedule A may be reduced to take into account the effect of any discount, overall limit or like reduction which has been agreed between that registered undertaking and the private hospital concerned.

12. If a person to whom prescribed health services are provided is an insured person under more than one health insurance contract (other than any such contract which relates solely to ancillary health services and/or solely to the public hospital daily in-patient charges made under Regulations pursuant to Section 53 of the Health Act, 1970 ) the prescribed minimum payment to be made under each such health insurance contract in respect of such prescribed health services shall be the prescribed minimum payment determined in accordance with articles 5 to 11 divided by the total number of such health insurance contracts.

13. The prescribed minimum payment may be made by the registered undertaking either to the health services provider or to the person who effected the health insurance contract under which the recipient of the prescribed health services is an insured person, depending upon the terms of the contract, and subject always to the requirements of section 15 of the Finance Act, 1987 .

14. Notwithstanding articles 5 and 6, in the case of a restricted membership undertaking lawfully carrying on health insurance business in the State on the 30th day of June 1994 and covering less than 1,500 insured persons at that date, the prescribed minimum payments (and where relevant the total periods over which such payments are required to be made) for the prescribed health services specified under the said articles shall be subject to a maximum of the lowest level of cover provided for those services under the rules of that undertaking at the date on which these regulations shall come into operation.

15. Notwithstanding sub-articles (3) and (4) of article 5, in the case of a restricted membership undertaking lawfully carrying on health insurance business in the State on the 30th day of June 1994 and covering 1,500 or more insured persons at that date, the prescribed minimum payments (and where relevant the total periods over which such payments are required to be made) for the prescribed health services specified under the said sub-articles shall be subject to a maximum of the lowest level of cover provided for those services under the rules of that undertaking at the date on which these regulations shall come into operation.

Schedule A

-Hospital Charges (In-patient and Day-patient Services)

1. The prescribed minimum payments in this Schedule relate to prescribed health services (other than those special procedures listed in Table B.1 of Schedule B of these Regulations) provided by a private hospital, and prescribed health services provided by a publicly-funded hospital or a registered nursing home, to an insured person as in-patient services or day-patient services. Prescribed minimum payments shall be determined as follows

In respect of:

Prescribed Minimum Payment

1.

Prescribed health services which are in-patient services provided by a publicly-funded hospital while the insured person was maintained in accommodation other than private hospital accommodation.

The public hospital daily in-patient charges made under regulations pursuant to Section 53 of the Health Act, 1970 .

2.

Prescribed health services which are in-patient services provided by a publicly-funded hospital while the insured person was maintained in private hospital accommodation.

The amount of the charge payable under Section 55 of the Health Act 1970 , reduced by 40 in the case of charges arising in respect of a period or periods during which the insured person was accommodated in a single room, plus the amount of the public hospital daily in-patient charges made under regulations pursuant to %Section 53 of the Health Act, 1970 .

3.

Prescribed health services (other than special procedures listed in Table B.1 of Schedule B) which are in-patient services provided by a private hospital, other than a private psychiatric hospital.

The lesser of: (a) £135 for each in-patient day; or (b) 60% of (i) the charge made by the private hospital; less (ii) £40 for each day during which the insured person was accommodated in a single room

4.

Prescribed health services which are day-patient services provided by a publicly-funded hospital while the insured person was maintained in private hospital accommodation.

The amount of the charge payable under Section 55 of the Health Act, 1970 .

5.

Prescribed health services which are day-patient services provided by a private hospital, other than a private psychiatric hospital.

The lesser of: (a) £135 for each day patient day; or (b) 60% of (i)the charge made by the private hospital; less(ii) £40 for each day during which the insured person was accommodated in a single room.

6.

Prescribed health services which are in-patient services provided by a private psychiatric hospital.

The lesser of: (a) £65 for each in-patient day; or (b) 60% of the charge made by that hospital;

7.

Prescribed health services which are in-patient services provided by a registered nursing home.

£20 per day, subject to a maximum of £280 respect of any particular continuous period during which an insured person was in receipt of such prescribed health services.

2. The amount determined under paragraph I in respect of hospital charges relating to childbirth by means of a normal vaginal delivery shall be £300.

Schedule B

— Special Procedures

1. The prescribed minimum payments in this Schedule relate to prescribed health services which are the special procedures listed herein and which are provided by a private hospital to an insured person while that person is maintained in private hospital accommodation for in-patient services orday-patient services.

2. The prescribed minimum payment shall be 35% of the procedure benefit derived from Table B.1 of this Schedule.

TABLE B.1

Procedure

Procedure Description

Procedure

Code

Benefit

(£)

5801

Exploration of mediastinum

940

5802

Endoscopic extirpation of lesion of mediastinum

940

5803

Diagnostic endoscopic examination of mediastinum

940

6675

Angiogram (direct puncture, single vessel study, brachial, femoral)

1,238

5945

Cardiac catheterisation with digital subtraction angiography

1,270

5080

Cardiac catheterisation (left, right or both sides)

1,306

5085

Cardiac angiography (left, right or both sides)

1,306

5090

Cardiac catheterisation and cardiac angiography combined

1,306

2676

Vitroctomy

2,354

5520

Valve shunt (hydrocephalus) - (Brain and Meninges)

2,756

5730

Cervical disc, partial excision of or fusion

2,866

5862

Cardiac Pacemaker System introduced through vein (Single Chamber)

3,032

5067

Cardiac Pacemaker System introduced through vein (Dual Chamber)

3,032

5068

Insertion of antitachycardia pacemaker

3,032

5069

Insertion of automatic implantation cardioverter/defibrillator

3,032

5525

Valve shunt revision - (Brain & Meninges)

3,032

5660

Craniotomy

3,721

3595

Spinal fusion anterior & posterior

4,410

3596

Spinal fusion, in scoliosis spine, anterior and posterior

4,410

3601

Spinal fusion with instrumentation

4,410

5101

Angioplasty (Coronary)

4,410

5962

Plastic repair of aorta (Coarctation/Interrupted Aortic Arch)

5,181

5957

Revision repair of coarctation of aorta

5,181

5893

Open Operations on pulmonary artery

5,209

5735

Cervical spondylosis, laminectomy, etc.

5,435

5480

Posterior fossa tumours, removal of

5,512

5470

Pituitary gland, hypophysectomy

5,677

5075

Blalock Operation

5,788

5870

Myocardial aneurysmyotomy

5,788

5811

Atrial inversion for transposition of great vessels

5,788

5812

Other correction of transposition of great vessels

5,788

5814

Closure of defect of atrioventricular septum using dual prosthetic patch

5,788

5817

Closure of defect of interventricular septum

5,788

5818

Planned repair of post infraction ventricular septal defect

5,788

5819

Emergency repair of post infraction ventricular septal defect

5,788

5958

Revision closure of defect of intra-ventricular septum

5,788

5813

Correction of total anomalous pulmonary venous connection

5,788

5872

Excision of pericardium

5,788

5809

Correction of tetralogy of fallot

5,788

5871

Open correction of patent ductus arteriosus

5,788

5882

Closed correction of patent ductus arteriosus

5,788

5875

Shoulder replacement prosthesis

6,107

5555

Acoustic neuroma, removal of

6,173

1246

Arterial bypass, popliteal artery

6,284

5865

Repair of ascending aortic aneurysm

6,284

3300

Arthroplasty (Forearm & Elbow)

7,186

5942

Lobectomy of Lung (including excision of segment)

7,717

5831

Plastic repair of mitral valve

8,268

5833

Replacement of tricuspid valve (includes valvuloplasty)

8,268

5855

Annuloplasty

8,268

5839

Double valves

8,268

5842

Triple valves

8,268

5843

Valve and grafts

8,268

5959

Revision of valve surgery

8,268

5816

Closure of defect of interatrial septum

8,599

5821

Other open operations on the septum of the heart

8,599

5824

Refashioning of atrium (Ebstein's)

8,599

5826

Operations on wall of atrium

8,599

5832

Replacement of aortic valve (includes valvuloplasty)

9,922

5836

Open Valvotomy

9,922

5055

Aortic endarterectomy

9,922

5829

Replacement of mitral valve (includes valvuloplasty)

9,922

5844

Saphenous vein graft bypass for coronary artery(ies)

9,922

5846

Autograft bypass for coronary artery(ies)

9,922

5847

Allograft bypass for coronary artery(ies)

9,922

5848

Prosthetic bypass for coronary artery(ies)

9,922

5849

Connection of mammary artery(ies) to coronary artery(ies)

9,922

5851

Connection of other thoracic artery(ies) to coronary artery(ies)

9,922

5852

Correction of anomalous coronary arteries

9,922

5853

Other open operation(s) on coronary artery(ies)

9,922

5904

Revision of prosthesis of aorta

9,922

5956

Revision coronary artery surgery

9,922

5099

Coronary artery bypass grafts and angiogram

10,970

4283

Allogeneic bone marrow transplantation, (complete procedure)

27,560

4284

Autologous bone marrow transplantation (complete procedure)

27,560

Schedule C

— Consultants' Fees (In-Patient and Day-Patient Services)

1. Definitions

"consultant anaesthetist" means a hospital consultant whose designated speciality is anaesthesia;

"consultant pathologist" means a hospital consultant whose designated speciality is pathology;

"consultant radiologist" means a hospital consultant whose designated speciality is radiology;

"in-patient attendance" means a period during which a hospital consultant is responsible for the care of an insured person;

"linked procedure" means a linked surgical procedure, or a radiological procedure, which is carried out in conjunction with other radiological procedures;

"linked surgical procedure" means a surgical procedure which is performed in conjunction with other surgical procedures during the same theatre session;

"pathological procedure" means a service, treatment or procedure listed in Table C.4 of this Schedule;

"radiological procedure" means a service, treatment or procedure listed in Table C.3 of this Schedule and therapeutic/invasive procedures listed in Table C.2 of this Schedule;

"surgical procedure" means a service, treatment or procedure listed in Table C.2 of this Schedule.

2. The prescribed minimum payments in this Schedule relate to prescribed health services which are provided by a hospital consultant to an insured person for in-patient services or day-patient services while that person is maintained in private hospital accommodation or in a recognised intensive care unit.

3. The prescribed minimum payment in respect of the participation by a consultant anaesthetist in a surgical or radiological procedure, that procedure not being an integral part of another more serious procedure performed at the same time, shall be the anaesthetic procedure benefit as set out in Tables C.2 or C.3 respectively of this Schedule except that if that procedure is a linked procedure the prescribed minimum payment shall be that anaesthetic procedure benefit multiplied by a value derived from the following table

Value

For the linked procedure which has the greatest anaesthetic procedure benefit of all related linked procedures

1.00

For all other linked procedures

0.00

4. The prescribed minimum payment in respect of a period of in-patient attendance by a consultant anaesthetist on an insured person in a recognised intensive care unit shall be—

(a) determined in accordance with Table C.1 of this Schedule if that attendance arises in other than a post surgical context; and

(b) £45 if that attendance arises in a post surgical context provided that this payment shall only fall due for care on or after the third post operative day.

5. The prescribed minimum payment in respect of in-patient attendance by a hospital consultant, other than a consultant anaesthetist, shall be the in-patient attendance benefit determined in accordance with Table C.1 of this Schedule except that no payment shall fall due if that attendance arises:—

(a) in conjunction with a surgical procedure performed by that hospital consultant other than as provided under paragraph 7; or

(b) during a stay in a private psychiatric hospital.

6. The prescribed minimum payment in respect of an in-patient consultation is £33 and falls due when the admitting hospital consultant responsible for the care of an insured person refers that person to another hospital consultant for an opinion, other than where such a referral is a routine matter of policy, and shall be payable once only, irrespective of the number of examinations or visits required to form an opinion.

7. The prescribed minimum payment in respect of a surgical procedure performed by a hospital consultant, other than a consultant anaesthetist, that procedure not being an integral part of another procedure performed at the same time, shall be the surgical procedure benefit as set out in Table C.2 of this Schedule except that—

(a) where that procedure is a linked surgical procedure the prescribed minimum payment shall be that surgical procedure benefit multiplied by a value derived from the following table—

Value

For the linked surgical procedure which has the greatest surgical procedure benefit of all related linked surgical procedures

1.00

For the linked surgical procedure which has the second greatest surgical procedure benefit of all related linked surgical procedures

0.50

For the linked surgical procedure which has the third greatest surgical procedure benefit of all related linked surgical procedures

0.25

For all other linked surgical procedures

0.00

(b) notwithstanding subsection (a) herein where that procedure is designated as "I.P." and is a linked surgical procedure no prescribed minimum payment shall fall due;

(c) where that procedure is designated "Diagnostic" the prescribed minimum payment shall be—

(i) if the insured person is maintained in private hospital accommodation for a period of three in-patient days or less, the greater of the surgical procedure benefit and the in-patient attendance benefit for that period determined in accordance with Table C.1; and

(ii) if the insured person is maintained in private hospital accommodation for a period of more than three in-patient days, the sum of the surgical procedure benefit and the in-patient attendance benefit for that period.

(d) Notwithstanding subsection (a) herein where that procedure is designated as "*" and other surgical procedures so designated are carried out during the same in-patient stay or day-patient day the prescribed minimum payment shall be that surgical procedure benefit multiplied by a value derived from the following table:

Value

For the surgical procedure which has the greatest surgical procedure benefit of all such designated surgical procedures.

1.00

For all other such designated surgical procedures

0.00

8. The prescribed minimum payment in respect of a radiological procedure performed by a consultant radiologist, that procedure not being an integral part of another more serious procedure performed at the same time, shall be the radiological procedure benefit as set out in Table C.3 of this Schedule or the surgical procedure benefit set out in Table C.2 of this Schedule as appropriate, except that no payment for Magnetic Resonance Imaging shall fall due other than in respect of the following clinical indications:-

Suspected Multiple Sclerosis after appropriate clinical screening

Suspect leukodystrophies

Vascular malformations

Epilepsy - Temporal lobe type

Suspect posterior fossa tumours

IAMS - suspect acoustic neuromas with audiology screening

Pituitary - after Computerised Tomography screen

Lower cranial nerve palsies, i.e. meningeal processes

Encephalitis

Spine

-

Post-operative failed back

-

Spinal cord compression (acute)

-

Cervical radiculopathy with

neurological signs

-

Spinal dysraphism and

associated abnormalities

-

Patients having had previous

Computerised Tomography or

myelogram which was in

conflict with the patient's

symptoms/signs

-

Intrinsic spinal cord disease

including cervical myelopathy

Bone Tumours

-

Staging of primary malignant

bone tumours

-

Soft tissue tumours for dialnosis

and staging

Shoulder Joint

-

Rotator cuff tears

Knee Joint

-

Assessment of menisceal tears,

cruciate ligament injuries and

losse bodies (but only when

clinically indicated in

preference to an arthroscopy)

Abdomen

-

Possible assessment of patients

with known liver tumours for

resection (previous dynamic

Computerised Tomography and ultrasound scans will have to have been performed)

Assessment of the inferior vena cave in patients with known solid renal tumours

9. The prescribed minimum payment in respect of a pathological procedure performed by a consultant pathologist shall be the procedure benefit as set out in Table C.4 of this Schedule, except that for each hospital admission a payment shall be due only once for any of the procedures comprising a designated group. A designated group is any of the following groups of pathological procedures:

(a) Category 1 and 1(A) combined

(b) Category 5(A)

(c) Category 8(A)

(d) Category 9

10. In respect of each episode of radiotherapy the prescribed minimum payment to a consultant anaesthetist shall be £69 and the prescribed minimum payment to a hospital consultant, other than a consultant anaesthetist, shall be £50.

11. In respect of surgical procedures coded from 1636 to 1639 on Table C.2 of this Schedule only an in-patient attendance benefit determined in accordance with Table C.1 of this Schedule shall be payable if these are performed other than while an insured person is in receipt of day-patient services.

Table C.1

Period of Attendance

In Patient Attendance Benefit

1 day

£ 50

2 days

£ 50

3 days

£ 50

4 days

£ 50

5 days

£ 50

6 days

£ 50

7 days

£ 59

8 days

£ 67

9 days

£ 75

10 days

£ 84

11 days

£ 92

12 days

£ 100

13 days

£ 109

14 days

£ 117

15 days

£125

Periods in excess of 15 days

£8 for each day in excess of 15 days

plus £125

TABLE C.2

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

GENERAL SURGICAL OPERATIONS

ABDOMINAL WALL and PERITONEUM:

5

Abdominal wall, secondary suture of

107

69

15

Laparotomy, division of adhesions

179

69

I.P.

20

Intra abdominal injury with rupture of viscus

322

107

I.P.

25

Intra abdominal injury, multiple complicated with rupture of viscus

394

154

I.P.

30

Laparotomy

144

69

I.P.

35

Laparoscopy with or without biopsy

107

54

I.P.

45

Omentopexy (otherwise)

144

69

50

Paracentesis abdominis

36

0

60

Pelvic abscess, drainage of

54

38

61

Percutaneous transabdominal biopsy

72

38

Diagnostic

80

Peritoneum, drainage of

144

69

I.P.

90

Laparotomy, intra-abdominal sepsis

287

69

I.P

5835

Peritoneal - venous shunt for ascites

287

92

ADRENAL GLANDS:

95

Adrenalectomy (unilateral)

287

107

I.P.

100

Adrenalectomy (bilateral)

358

107

I.P.

101

Adrenalectomy for phaeochromocytoma

287

107

105

Adrenal glands - any other operations

287

107

106

Neuroblastoma, tru cut biopsy

66

38

Diagnostic

107

Neuroblastoma, resection

456

177

APPENDIX:

110

Appendicectomy (with or without complications)

144

69

I.P.

GALL BLADDER and BILE DUCTS:

115

Cholecystojejunostomy

287

107

116

Choledochojejunostomy (Roux - en - Y)

432

107

117

Choledochoduodenostomy

314

107

118

Surgical repair of post-operative bilary stricture

471

107

129

Hepaticojejunostomy

432

107

132

Cholecystectomy with exploration of common bile duct

394

107

135

Cholecystectomy (including laparoscopic method) and per operative cholangiogram

287

69

136

Percutaneous removal of gallstones from the bile ducts

179

69

140

Cholecystostomy with exploration, drainage or removal of calculus

179

69

145

Hepaticoduodenostomy

358

107

150

Transduodenal sphincteroplasty with or without transduodenal extraction of calculus

322

107

151

Transhepatic insertion of biliary endoprosthesis

215

92

152

Percutaneous insertion of gall bladder catheter for MTBE installation Including catheter removal

179

69

153

Insertion of naso biliary tube and administration of CDC/URSO

179

69

GASTRIC OPERATIONS:

155

Antrectomy and drainage

358

69

165

Duodenal diverticula, excision of

322

92

175

Gastrectomy total or revision

430

131

180

Gastrectomy (sub total)

358

92

190

Gastroenterostomy

287

69

195

Gastroscopy or gastroduodenoscopy (fibroscope)

54

38

I.P.

Diagnostic

196

Upper G.I. endoscopy and biopsies

54

38

Diagnostic

197

Upper G.I. endoscopy and polypectomy

54

40

Diagnostic

200

Gastrostomy

215

69

201

Percutaneous gastrostomy

107

54

205

Gastrotomy/duodenotomy for haemorrhage

251

69

215

Oversewing perforated peptic ulcer

215

69

230

Rammstedt's operation

215

69

235

Stomach transection

358

69

240

Vagotomy and drainage or highly selective vagotomy

287

69

HERNIA:

245

Epigastric/Ventral hernia, repair of

144

54

I.P.

246

Exomphalos, minor

228

69

247

Exomphalos, major

448

177

248

Exomphalos. delayed

448

177

250

Femoral hernia, repair of (bilateral)

268

69

255

Femoral hernia, repair of (unilateral)

179

54

I.P.

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

270

Hiatus hernia, abdominal repair of

322

92

271

Laparoscopic repair of hiatus hernia

322

92

275

Hiatus hernia, transthoracic, repair of

322

131

I.P.

280

Incisional hernia, repair of

287

54

I.P.

285

Inguinal hernia, repair of (bilateral)

215

69

I.P.

290

Inguinal hernia, repair of (unilateral)

144

54

I.P.

291

Strangulated inguinal hernia, unilateral

201

54

I.P.

295

Patent urachus, closure and repair of abdominal muscles

215

54

305

Recurrent hernia, repair of

215

69

I.P.

310

Umbilical hernia, repair of

144

54

I.P.

JEJUNUM and ILEUM:

320

Congenital defects, correction of (including Meckel's diverticulum)

144

69

331

Gastroschisis

531

177

355

Ileostomy

287

69

I.P.

360

Intestinal obstruction (including bowel resection)

287

92

361

Intestinal atresia, single/multiple

359

107

364

Hydrostatic reduction of intussusception

144

69

370

Jejunostomy

144

69

385

Resection and anastomosis of jejunum or ileum

287

69

LARGE INTESTINE:

389

Anal canal EUA

32

33

I.P.

390

Anal canal, plastic repair of (for incontinence)

215

69

395

Anal fissure, dilatation of anus for

36

38

I.P.

396

Anoplasty for low anorectal anomaly

215

69

397

Anorectal anomaly, (posterior sagittal anorectoplasty PSARP), for high/inter

424

177

400

Lateral internal sphincterotomy

72

42

I.P.

404

Parks' anal sphincter repair

424

177

405

Anal warts or papillae, removal of

54

38

I.P.

410

Anus, excision of epithelioma of, with colostomy

287

92

415

Anus, excision of epithelioma of, without colostomy

54

42

420

Caecostomy

287

92

I.P.

425

Caecostomy or colostomy, closure of

287

69

430

Colectomy, partial

287

92

435

Colectomy, total

358

154

436

Total colectomy and ileal pouch construction with temporary ileostomy

501

200

437

Closure of ileostomy

179

69

438

Total colectomy for toxic megacolon

573

177

450

Colonoscopy, one side

54

40

Diagnostic

455

Colonoscopy, both sides

144

40

Diagnostic

456

Colonoscopy plus polypectomy

72

40

Diagnostic

457

Colonoscopy plus polypectomy full colon

144

40

Diagnostic

458

Left colonoscopy and laser photocoagulation of rectum

107

40

459

Colonoscopy, full colon and laser photocoagulation of rectum

215

40

460

Colostomy

287

92

I.P.

465

Resection of bowel and colostomy or anastomosis for diverticulitis

322

92

470

Faecal fistula, closure or resection

358

92

485

Fistula in ano, excision

179

69

I.P.

490

Haemorrhoidectomy (external)

89

54

I.P.

495

Haemorrhoidectomy (external, multiple)

107

54

I.P.

500

Haemorrhoidectomy (internal)

144

54

I.P.

506

Haemorrhoids, injection and/or banding

36

0

I.P.

515

Imperforate anus, simple incision

36

38

520

Imperforate anus, with colostomy or pull through operation

287

107

525

Ischio rectal abscess, incision and drainage

107

38

I.P.

513

Meconium ileus, open reduction with or without stoma

359

107

514

Meconium ileus reduction

107

54

516

Necrotising enterocolitis, percutaneous drainage

76

38

517

Necrotising enterocolitis, laparotomy resection/stoma

359

107

530

Proctoscopy or sigmoidoscopy

36

38

I.P.

Diagnostic

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

535

Proctoscopy or sigmoidoscopy, with biopsy

36

38

I.P.

Diagnostic

536

Diagnostic flexible sigmoidoscopy and biopsies

36

40

I.P.

Diagnostic

540

Proctoscopy or sigmoidoscopy with biopsy of muscle coats of bowel, for megacolon

54

54

I.P.

Diagnostic

545

Prolapse of rectum, abdominal approach involving laparotomy, colostomy or intestinal anastomosis

358

107

549

Delorme procedure

286

107

550

Prolapse of rectum, perineal repair

107

69

I.P.

555

Rectal fistula, closure or repair

358

107

556

Balloon dilation of the rectum

72

54

560

Rectal or sigmoid polypi (removal by diathermy, etc)

107

54

565

Rectum, excision of (all forms including perineoabdominal, perineal anterior resection)

394

177

570

Rectum, partial excision of

394

177

574

Presacral teratoma, excision

537

177

575

Rectum (combined synchronous resection)

466

177

576

Revision/refashioning of ileostomy and duodenostomy, complicated reconstruction in - depth

179

69

I.P.

577

Low anterior resection with coloanal anastomosis for cancer

608

177

578

Soave procedure

608

177

580

Sigmoid myotomy (Reilly's operation)

161

69

581

Sigmoidoscopy including dilatation of intestinal strictures

89

38

585

Stricture of rectum (dilation of)

36

38

I.P.

590

Volvulus (stomach, small bowel or colon, including resection and anastomosis)

358

107

LIVER:

595

Hepatotomy for drainage of abscess or cyst, one or two stages

144

69

600

Biopsy of liver (by laparotomy)

144

69

I.P.

Diagnostic

601

Transjugular liver biopsy

144

54

Diagnostic

605

Biopsy of liver (needle)

72

38

Diagnostic

610

Haemangioma of liver

144

131

611

Major liver resection

786

261

612

Kasai type liver resection

456

131

616

Wedge resection of liver

236

131

617

Intrahepatic cholangioenteric anastomosis

511

131

618

Resection of hilar bile duct tumour

608

261

619

Liver trauma

511

261

622

Insertion of hepatic artery catheter and reservoir pump

179

69

625

Left lateral lobectomy

430

261

630

Excision of hydatid cyst

315

131

MALE GENITAL TRACT:

635

Circumcision (over 6 years)

72

38

640

Circumcision (under 6 years)

72

54

645

Epididymectomy

144

54

I.P.

650

Hydrocele (tapping)

36

38

655

Hydrocele, radical operation, bilateral

215

69

I.P.

660

Hydrocele, radical operation, unilateral

144

54

I.P.

665

Meatotomy

54

38

670

Orchidectomy, bilateral

144

69

I.P

675

Orchidectomy, unilateral

107

54

I.P

680

Orchidectomy with radical removal of lymph nodes

358

107

681

Injection of corpora cavernosa with pharmacologic agent(s) (e.g.papaverine, phentolamine)

36

38

685

Penis, amputation of partial

179

69

686

Chordee release of

144

69

690

Penis, amputation of - with block dissection of glands

358

69

691

Transcatheter embolosation for relief of priapism

215

69

695

Prepuce, dorsal incision of

54

38

700

Prostatectomy

287

69

701

Radical retropubic nerve sparing prostatectomy (includes bilateral

701

pelvic lymph adenectomy with bladder neck reconstruction and anastomosis to the urethra).

430

177

702

Transurethral microwave thermotherapy to the prostate (TUMT)

215

69

703

Insertion of an endo urethral stent for prostate obstruction

215

69

705

Spermatocele or spermatic cyst, (simple ) excision of

144

54

706

Spermatocele or spermatic cyst, (multiloculate) excision of

144

54

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

710

Testes, agenesis of - bilateral exploration of inguinal canals and pelvis

251

92

711

Electro ejaculation procedure

72

38

715

Testicle, imperfectly descended, orchidopexy

107

69

I.P.

720

Testicle, imperfectly descended bilateral orchidopexy

144

69

725

Testicle, imperfectly descended, associated with inguinal hernia

144

69

I.P.

730

Testes, imperfectly descended, associated with bilateral inguinal hernia

215

92

735

Testes, unilateral orchidopexy and exploration of opposite side

215

69

740

Testicular biopsy (needle)

54

38

Diagnostic

741

Testicular biopsy

107

38

Diagnostic

742

Insertion of testicular prosthesis, unilateral

144

38

745

Reduction of torsion of testicle

72

54

749

Transcatheter management of varicocele, including testicular venography

179

69

750

Varicocele, bilateral removal

251

92

755

Varicocele, unilateral removal

179

54

760

Vasotomy or ligation of vas

72

38

I.P.

765

Vas, reconstruction of (unilateral)

233

75

770

Vas. reconstruction of (bilateral)

322

92

PANCREAS:

771

ERCP sphincterotomy and extraction of stones

198

54

772

ERCP sphincterotomy and insertion of endoprosthesis

215

69

774

ERCP (endoscopic retrograde cholangiogram of pancreas)

179

54

Diagnostic

775

Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple - type procedure); with pancreatojejunostomy

775

501

200

776

Pancreatic biopsy

215

92

Diagnostic

778

Pancreaticojejunostomy

466

154

780

Distal pancreatectomy

358

131

789

Total pancreatectomy, distal gastrectomy, splenectomy, duodenectomy,cholecystectomy and resection of distal bile duct

785

501

200

786

Simultaneous pancreas/kidney transplant

609

307

790

Drainage of pancreatic abscess or pseudocyst

358

200

795

Pancreatotomy for drainage of pancreatitis, abscess or cyst with exploration of biliary and pancreatic duct

430

200

SPLEEN:

800

Splenectomy

287

92

I.P.

806

Transcatheter ablation of function of spleen

215

69

807

Aspiration of splenic cysts

107

54

URINARY TRACT:

815

Aberrant vessels, division of

358

69

822

Permacath Hickman catheter for dialysis

179

69

823

Home based haemodialysis self dialysis training (max. 18 sessions)

22

0

824

Haemodlatysis, chronic, in patient's home or at hospital out patient department, after

824

completion of training sessions (minimum of three dialysis sessions per week inclusive of all consultant care) monthly benefit

134

0

825

Artificial kidney, use of (pre shunt) (haemodialysis, surgical fee)

89

0

826

Chronic haemodialysis (post shunt) 1st 12th treatment

36

0

827

Chronic haemodialysis (post shunt) 13th treatment onwards

36

0

828

Acute intermittent haemodialysis 1st 12th treatment

54

0

829

Acute intermittent haemodialysis 13th treatment onwards

54

0

830

Artificial kidney, use of (peritoneal dialysis)

89

0

831

Chronic peritoneal dialysis, hospital based establishment of therapy (1st 12th day)

36

0

832

Chronic peritoneal dialysis (hospital based after 12th day)

36

0

Peritoneal dialysis, chronic, in the patient's home or at hospital out

833

patient department, after completion of training sessions (minimum of three dialysis sessions per week inclusive of all consultant care) monthly benefit

151

0

834

Tenchkoff catheter for CAPD dialysis

144

69

835

Bladder, implantation of radioactive source

179

54

836

Bladder, instillation of anticarcinogenic agent (BCG)

54

38

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

837

Continuous veno venous haemofiltration dialysis (CVVHD), per day

54

0

840

Bladder - rupture of (simple)

215

69

845

Bladder - rupture of (complicated traumatic)

287

154

850

Bladder neck, transurethral resection of

144

54

855

Bladder tumour, diathermy to, primary resection

215

69

860

Bladder tumour, repeat diathermy

72

54

865

Cystectomy, partial

251

69

870

Cystectomy, with re-implantation of ureters

358

131

875

Cystectomy with ileal or sigmoid loop and bowel anastomosis

484

200

876

Cystectomy with ileal or sigmoid loop and bowel anastomosis including continent catheterizable diversion

538

200

877

Cystectomy with ileal or sigmoid loop and bowel anastomosis including neo bladder with urethral re anastomosis

609

223

880

Cystoscopy with or without biopsy

54

38

Diagnostic

881

Cystoscopy and removal of JJ stent

107

54

885

Cystoscopy with intravesical operation (diathermy, etc.)

89

54

886

Therapeutic overdistension of the bladder

54

38

I.P.

890

Cystoscopy with ureteric catheterisation including retrograde pyelography

72

54

I.P.

Diagnostic

895

Cystoscopy with removal of ureteric calculus

144

54

900

Cystoscopy with ureteric dilatation or meatotomy

107

54

905

Cystotomy

144

69

906

Augmentation cystoplasty (ileo caeco cystoplasty, colocystoplasty)

358

200

910

Diverticulum of bladder, excision or obliteration of

287

69

915

Embolisation of haemangioma of kidney

251

92

920

Hemi nephrectomy

251

92

923

Kidney transplant

501

200

924

Litholapaxy: Crushing or fragmentation of calculus by any means, in the bladder, including ultrasonic destruction

215

69

925

Nephrectomy

322

92

926

Nephrectomy and caval extension below liver

394

107

927

Nephrectomy and caval extension of tumour above liver

520

154

928

Nephrectomy with caval invasion

592

223

930

Nephrolithotomy

358

69

931

Percutaneous nephrolithotomy, unilateral

215

92

932

Percutaneous nephrolithotomy, bilateral

322

92

933

Percutaneous nephrolithotomy, staghorn

322

92

934

Percutaneous nephrostomy with or without antegrade pyelogram or stent placement

251

92

935

Peri renal tissues, exploration, open biopsy (no abnormality discovered)

215

92

I.P.

936

Percutaneous tract formation for renal stone removal

144

54

940

Pyelolithotomy

358

69

945

Pyeloplasty

394

92

950

Pyelotomy

215

69

955

Renal biopsy (needle)

72

38

Diagnostic

956

Renal cyst puncture and aspiration

107

54

960

Suprapubic cystostomy

107

69

I.P.

965

Suprapubic fistula, closure of

215

92

966

Transcatheter ablation of function of kidney

215

69

967

Transcatheter ablation of function of adrenal

215

69

970

Ureteric fistula, closure of (including uretero-vaginal and vesico - vaginal)

287

92

975

Ureterolithotomy

215

69

980

Ureterolithotomy (bilateral)

322

92

981

Ureterolysis (unilateral)

287

69

982

Ureterolysis (bilateral)

430

92

984

STING procedure

215

54

985

Ureters, transplantation of, (bilateral)

430

92

990

Ureter, transplantation of, (unilateral)

322

69

991

Stamey Raz urethropexy

215

69

995

Ureterostomy (unilateral)

215

69

1000

Ureterostomy (bilateral)

322

92

1005

Urethral rupture of (straddle injury), repair of

215

69

1010

Urethra rupture, repair of with fractured pelvis (orthopaedic surgeon)

358

154

1015

Urethral dilatation

36

38

I.P.

1020

Urethroscopy with treatment (diathermy)

72

38

I.P.

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

1025

Urethrostomy

144

54

I.P.

1030

Urethrotomy

72

42

l.P.

1031

Complex urodynamic evaluation involving cineradiology

72

54

Diagnostic

1032

Implantation of artificial urinary sphincter

358

69

1033

Whittaker test for evaluation of upper urinary tract obstruction

144

0

Diagnostic

1035

Vesicolic fistula, closure of

287

92

5845

Ileal conduit urinary diversion

430

131

5850

Cystoscopy and ureteroscopy

144

54

Diagnostic

5910

Lithotripsy, one or more sessions per hospital stay

215

69

5911

Lithotripsy including placement and removal of J stent and/or push ureteroscopy. one or more sessions per hospital stay

251

92

HEAD AND NECK

ARTERIES: (See also Neurological Section)

1041

Carotid body tumour greater than 4 cms

538

154

1042

Carotid body tumour less than 4 cms

394

92

CHEEK:

1045

Cyst or benign tumour of cheek or mouth, excision of

54

38

1050

Malignant growth of cheek, full thickness/wide excision of

287

69

1051

Malignant growth of cheek, superficial, excision of

126

69

JAWS:See E.N.T. and Plastic Sections.LIPS: (see also Plastic Section)

1055

Cyst or benign tumour on lip, excision of

54

38

1058

Epithelioma of lip, lip shave

72

54

1059

Epithelioma of lip, wedge excision

144

54

1060

Epithelioma of lip, excision and flap reconstruction

287

69

NECK:

1065

Branchial cyst, pouch or fistula, excision of

287

69

1075

Cysts or tuberculous glands of neck (deep to deep fascia) excision of

215

69

1080

Conservative neck dissection

287

107

1082

Radical neck dissection

342

107

1085

Thyroglossal cyst or fistula, excision of

287

69

1090

Torticollis, partial excision, open correction of

179

54

1095

Tuberculous caseous glands or sinuses, curettage of

72

38

PALATE: (See also Plastic Section)

1100

Laceration of palate, repair of

72

54

1105

Radical operation for malignant growth of palate

358

107

1104

Biopsy lesion of palate

34

38

MAXILLA:

1106

Partial maxillectomy including plastic reconstruction

268

69

1107

Total maxillectomy includinq plastic reconstruction

358

107

PARATHYROID GLANDS:

1110

Parathyroid adenoma, excision of

358

107

1111

Transcatheter ablation of function of parathyroid glands

215

69

1112

Parathyroid hyperplasia, excision of (4 glands - frozen section)

402

107

1113

Total parathyroidectomy with autotransplant or mediastinal exploration/intra-thoracic

475

107

1114

Parathyroid re-exploration

475

107

SALIVARY GLANDS:

1115

Abscess of salivary gland, incision and drainage

54

54

1120

Fistula of salivary duct, repair of

251

54

1125

Parotid or submandibular duct, dilatation of

36

38

1126

Submandibular duct, relocation

358

107

1130

Excision of parotid tumour or parotid gland, lateral lobe, (enucleation of)

287

54

1133

Excision of parotid tumour or parotid gland, lateral lobe (superficial parotidectomy) with dissection and preservation of facial nerve

268

54

1134

Excision of parotid tumour or parotid gland, total, en bloc removal with sacrifice of facial nerve

340

75

1135

Excision of parotid tumour or parotid gland, total with dissection and preservation of facial nerve

412

92

1140

Salivary calculus, removal of

72

54

1150

Submandibular salivary gland, excision of

107

54

1151

Excision of sublingual gland

108

54

THYROID GLAND:

1152

Thyroid cyst(s) aspiration/fine needle biopsy

29

0

I. P.

1154

Excision of thyroid cyst

252

92

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

1156

Percutaneous core needle biopsy of thyroid gland (for fine needle biopsy use procedure code 1152)

50

38

I.P.

Diagnostic

1155

Total/revision thyroidectomy

358

92

1157

Partial/subtotal thyroidectomy

344

92

TONGUE:

1165

Excision of epithelioma of tongue with radical operation on glands

358

92

1170

Frenectomy (tongue tie)

36

38

1175

Hemiglossectomy

179

54

1176

Total glossectomy

358

92

1180

Growths of tongue, diathermy to

36

38

1185

Excision biopsy, oral cavity

54

38

I.P.

1186

Resection of tonsil, tongue base, palate, mandible and radical neck dissection

683

261

BREAST:

1190

Abscess, incision and drainage of

54

38

1191

Breast cyst(s) aspiration/fine needle biopsy (diagnostic or therapeutic)

29

0

I.P.

1195

Percutaneous core needle biopsy of breast (for fine needle biopsy use procedure code 1191 )

54

54

I.P.

Diagnostic

1200

Cysts or benign tumours, excision of, or segmental resection

107

54

1205

Duct papilloma, excision

107

54

1210

Gynaecomastia (excision for), unilateral

134

54

1211

Gynaecomastia (excision for), bilateral

251

69

1214

Segmental mastectomy with axillary sampling

215

69

1215

Total mastectomy

215

69

1216

Mastectomy with axillary clearance

342

69

1217

Quadrant mastectomy with axillary clearance

342

69

1218

Mammographic wire guided breast biopsy

117

38

Diagnostic

LYMPHATICS:

1310

Axillary/inguinal lymph node(s) superficial dissection of

73

42

I.P.

1315

Axillary lymph nodes complete dissection of

251

69

1320

Axillary or inguinal lymph nodes, incision of abscess

73

38

1326

Deep cervical node excision biopsy (not needle biopsy)

73

38

Diagnostic

1335

Inguinal or pelvic lymph node block dissection, unilateral

268

92

I.P.

1336

Inguinal or pelvic lymph node block dissection, bilateral

402

92

I.P.

1355

Lymphatic infusion

179

0

1365

Primary or secondary retroperitoneal, lymphadenectomy complete, transabdominal

430

92

I.P.

MUSCLES:

1370

Haemangioma of muscle, excision and repair of

215

69

1375

Muscle, manipulation and stretching of

36

0

1380

Muscle, repair and suture of

144

54

1385

Muscle biopsy

54

38

Diagnostic

NERVES: (See also E.N.T.and Plastic Sections)

1390

Nerve biopsy

107

38

Diagnostic

1395

Nerve repairs (primary)

287

69

I.P.

1400

Nerve suture (secondary, including grafting and anastomosis)

322

69

1405

Neurectomy or local excision of neuroma

215

54

TENDONS:(See also Orthopaedic and Plastic Sections)

1410

Tendon repairs (primary) single

144

69

1415

Tendon repairs (primary) multiple

287

92

1420

Tendon sheath, incision of

72

38

1425

Tenotomy

72

38

1426

Tenolysis

144

69

VASCULAR:

1427

Supra - renal aneurysm repair

573

223

1428

Repair of super renal aortic aneurysm rupture

573

223

1429

Tube graft repair of abdominal aorta

573

223

1431

Repair of ruptured abdominal aortic aneurysm

573

223

1432

Aorto bi-iliac bypass for atherosclerosis or aneurysm

573

223

1433

Aorto-femoral or bifemoral bypass for atherosclerosis or aneurysm

573

223

1434

Endarterectomy of abdominal aorta and iliac vessels

573

223

1436

Repair of ruptured iliac artery aneurysm

573

223

1437

Endarterectomy of iliac vessels alone

573

223

1438

Visceral artery repair, re-anastomosis or endarterectomy

573

223

1439

Renal artery anastomosis, endarterectomy or re-implantation or bypass

573

223

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

1156

Percutaneous core needle biopsy of thyroid gland (for fine needle biopsy use procedure code 1152)

50

38

I.P.

Diagnostic

1155

Total/revision thyroidectomy

358

92

1157

Partial/subtotal thyroidectomy

344

92

TONGUE:

1165

Excision of epithelioma of tongue with radical operation on glands

358

92

1170

Frenectomy (tongue tie)

36

38

1175

Hemiglossectomy

179

54

1176

Total glossectomy

358

92

1180

Growths of tongue, diathermy to

36

38

1185

Excision biopsy, oral cavity

54

38

I.P.

1186

Resection of tonsil, tongue base, palate, mandible and radical neck dissection

683

261

BREAST:

1190

Abscess, incision and drainage of

54

38

1191

Breast cyst(s) aspiration/fine needle biopsy (diagnostic or therapeutic)

29

0

I.P.

1195

Percutaneous core needle biopsy of breast (for fine needle biopsy use procedure code 1191 )

54

54

I.P.

Diagnostic

1200

Cysts or benign tumours, excision of, or segmental resection

107

54

1205

Duct papilloma, excision

107

54

1210

Gynaecomastia (excision for), unilateral

134

54

1211

Gynaecomastia (excision for), bilateral

251

69

1214

Segmental mastectomy with axillary sampling

215

69

1215

Total mastectomy

215

69

1216

Mastectomy with axillary clearance

342

69

1217

Quadrant mastectomy with axillary clearance

342

69

1218

Mammographic wire guided breast biopsy

117

38

Diagnostic

LYMPHATICS:

1310

Axillary/inguinal lymph node(s) superficial dissection of

73

42

I.P.

1315

Axillary lymph nodes complete dissection of

251

69

1320

Axillary or inguinal lymph nodes, incision of abscess

73

38

1326

Deep cervical node excision biopsy (not needle biopsy)

73

38

Diagnostic

1335

Inguinal or pelvic lymph node block dissection, unilateral

268

92

I.P.

1336

Inguinal or pelvic lymph node block dissection, bilateral

402

92

I.P.

1355

Lymphatic infusion

179

0

1365

Primary or secondary retroperitoneal, lymphadenectomy complete. transabdominal

430

92

I.P.

MUSCLES:

1370

Haemangioma of muscle, excision and repair of

215

69

1375

Muscle, manipulation and stretching of

36

0

1380

Muscle, repair and suture of

144

54

1385

Muscle biopsy

54

38

Diagnostic

NERVES: (See also E.N.T,and Plastic Sections)

1390

Nerve biopsy

107

38

Diagnostic

1395

Nerve repairs (primary)

287

69

I.P.

1400

Nerve suture (secondary, including grafting and anastomosis)

322

69

1405

Neurectomy or local excision of neuroma

215

54

TENDONS: (See also E.N.T. and Plastic Sections)

1410

Tendon repairs (primary) single

144

69

1415

Tendon repairs (primary) multiple

287

92

1420

Tendon sheath, incision of

72

38

1425

Tenotomy

72

38

1426

Tenolysis

144

69

VASCULAR:

1427

Supra - renal aneurysm repair

573

223

1428

Repair of super renal aortic aneurysm rupture

573

223

1429

Tube graft repair of abdominal aorta

573

223

1431

Repair of ruptured abdominal aortic aneurysm

573

223

1432

Aorto bi-iliac bypass for atherosclerosis or aneurysm

573

223

1433

Aorto - femoral or bifemoral bypass for atherosclerosis or aneurysm

573

223

1434

Endarterectomy of abdominal aorta and iliac vessels

573

223

1436

Repair of ruptured iliac artery aneurysm

573

223

1437

Endarterectomy of iliac vessels alone

573

223

1438

Visceral artery repair, re-anastomosis or endarterectomy

573

223

1439

Renal artery anastomosis, endarterectomy or re-implantation or bypass

573

223

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

1441

Embolectomy of visceral branches, superior mesenteric or renal arteries

287

107

1442

Removal of infected aortic prosthesis

736

307

1443

Obturator bypass from aorta or iliac to profunda or distal femoral bypass

358

154

1444

Repair of abdominal aortic trauma

358

154

1446

Aortic exclusion by axillo-femoral bypass

358

154

1447

Endarterectomy of internal/external common carotid artery with or without shunt

573

223

1448

Patch repair of internal carotid artery

236

107

1449

Vertebral artery bypass or repair

528

154

1451

Open repair of subclavian artery

358

154

1454

Translocation of common carotid to subclavian artery

287

154

1456

Carotid subclavian bypass

287

200

1457

Subclavian/subclavian bypass

287

154

1458

Thoracotomy with repair of vessels of arch of aorta

573

223

1285

Intra arterial injection (excluding arteriography)

54

0

I.P.

1305

Renal stenosis, repair of

358

177

1306

Transcatheter embolisation

215

107

1307

Transcatheter removal of intravascular thrombus or foreign body

215

107

5866

Percutaneous angioplasty

215

131

VASCULAR - HEAD. NECK and UPPER LIMBS:

1459

Subclavian to branchial bypass or endarterectomy

287

200

1461

Repair of subclavian aneurysm

287

200

1462

Brachial embolectomy

287

107

1463

Repair or bypass of brachial to radial or ulnar vessel

358

154

1464

Repair of trauma to brachial artery with endarterectomy patch or bypass

447

154

820

Arterial venous fistula in arm under L.A.

144

92

821

Gortex graft placement for AV access for dialysis

322

69

1290

Ligation of major vessels

179

54

1250

Arterial biopsy (temporal artery biopsy bilateral under L.A.)

72

54

Diagnostic

VASCULAR - LOWER LIMBS:

1467

Femoral popliteal bypass, above knee vein

358

154

1468

Femoral to popliteal bypass, above knee synthetic

358

154

1469

Femoral to popliteal bypass, below knee vein

358

154

1471

Femoral to popliteal bypass, below knee synthetic

358

154

1472

Profundaplasty with or without patch or endarterectomy

358

154

1473

Common femoral artery endarterectomy

215

107

1474

Repair of femoral artery aneurysm

358

154

1280

Common femoral artery embolectomy

215

107

1476

Popliteal artery embolectomy

358

154

1477

Tibial artery embolectomy

358

154

1478

Femoral tibial artery bypass, including tibial-peroneal and peroneal artery bypass, or other distal vessels

573

223

1479

Popliteal aneurysm artery repair or bypass

358

154

1481

Femoral/femoral bypass

358

154

1482

Repair of femoral or popliteal vessels due to trauma

358

154

VARICOSE VEINS:

1483

Ligation and division at the sapheno-femoral junction and complete stripping of the long saphenous vein, ligation and division of the short saphenous vein at the sapheno popliteal junction,ligation and avulsion of multiple varicose veins, for both legs

287

69

1484

As 1483 for one leg

198

54

1486

Ligation and division at the sapheno-femoral junction of the long saphenous vein with complete stripping of the long saphenous vein and ligation and avulsion of multiple varicose veins in the leg (both legs)

215

69

1487

Ligation and division at the sapheno-femoral junction of the long saphenous vein with complete stripping of the long saphenous vein with ligation and avulsion of multiple varicose veins in the leg (one leg) Ligation and division of the short saphenous vein at the sapheno

144

54

1488

Ligation and division of the short saphenous vein at the sapheno popliteal junction with ligation and avulsion of multiple varicose veins in the leg (both legs) Ligation and division of the short saphenous vein at the sapheno

215

69

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

1489

Ligation and division of the short saphenous vein at the sapheno popliteal junction plus ligation and avulsion of multiple varicose veins in the leg (one leg)

144

54

1491

Cockett, Linton or Dodd procedure on perforators Ligation and division at the sapheno-femoral junction of the long

287

69

I.P.

1492

saphenous vein with ligation and avulsion of multiple varicose veins, one or both legs

144

54

1430

Iliac or femoral veins, removal of thrombus from

179

69

1435

Inferior vena cava, ligation or clipping of, with or without removal of thrombus

287

107

1440

Ligation and division of individual perforator

54

54

I.P.

1450

Portosystemic shunt

394

177

1455

Sclerosing operation on vein(s), one leg

36

0

I.P.

1460

Sclerosing operation on veins, both legs

54

0

I.P.

1465

Splenorenal anastomosis

358

177

1490

Varicose veins, exploration and removal of thrombus, unilateral

179

54

1495

Varicose veins, exploration and removal of thrombus, bilateral

215

69

1500

Venous pressure and blood volume studies

36

0

Diagnostic

SKIN and SUBCUTANEOUS TISSUES:

1505

Abscess, cyst or tumour, aspiration of

36

38

1506

Angioma cauterisation or injection into, under general anaesthetic

36

38

1507

Angioma of skin and subcutaneous tissue or mucous surfaces, small, excision and repair of, under general anaesthetic

54

38

1508

Angioma of skin and subcutaneous tissue or mucous surfaces, large,.excision and repair of, under general anaesthetic

107

54

1509

Biopsy of skin, subcutaneous tissue and/or mucous membrane including simple closure

52

0

Diagnostic

1510

Excision and biopsy/curettage of a seborrhoeic keratosis / basal cell papilloma (single or multiple)

54

38

1513

Ellipse biopsy of the skin

70

0

Diagnostic

1514

Cryotherapy or curettage to solar or actinic keratosis or warts other than plantar (single or multiple)

54

38

1525

Foreign body, removal of

54

38

1540

Skin abscess, (superficial) incision and drainage of

54

38

1545

Keloid or other scar, excision of

54

38

1546

Enucleation of lipoma

72

54

1550

Malignant melanoma, wide excisional biopsy

107

69

1551

Malignant melanoma, wide excisional biopsy and graft

215

69

(See "LYMPHATICS" for block dissection of glands)

1555

Excision of pigmented naevi

54

38

1560

Incision and drainage of pilonidal abscess

52

38

1561

Pilonidal sinus or cyst, excision of

144

54

1565

Tubed pedicle flap, per stage

215

92

1570

Removal of foreign body from hand or foot under anaesthetic

54

54

1575

Basal cell carcinoma / squamous cell carcinoma, simple excision

107

69

1576

Basal cell carcinoma / squamous cell carcinoma, excision and graft or local flap

215

69

1577

Basal cell carcinoma / squamous cell carcinoma, curettage and/or electrosurgery

126

69

1580

Excision of a sebaceous cyst(s) (single or multiple)

72

38

1586

Laser treatment to naevi, initial patch test

54

38

1587

Laser treatment to naevi, each subsequent treatment session

107

38

1588

Excision of axillary skin for hyperhidrosis

144

54

1591

Hydradenitis suppurativa, excision and suture

89

38

1592

Hydradenitis suppurativa, excision and graft

215

69

1605

Surgical diathermy under general anaesthetic for any condition other than those listed separately

72

38

1610

Interstitial implant with radioactive source

72

54

1615

Wounds and sinuses, curettage of

54

38

1620

Wounds (multiple), suture or excision and suture

107

54

1625

Simple repair of superficial wounds

52

38

OTHER PROCEDURES:

1630

Exchange transfusion

107

0

1635

Exchange transfusion (intra uterine)

144

0

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

1631

Hyperbaric oxygen therapy, initial, including full medical evaluation

107

0

1632

Hyperbaric oxygen therapy, subsequent, per session

36

0

1636

Intravenous immunoglobulin for patients with a haematological malignancy or immune deficiencies

35

0

1637

Blood transfusion for patients with a haematological malignancy or immune deficiencies

35

0

1638

Intravenous antibiotics for patients on cytotoxic chemotherapy regimens for malignant disease

35

0

1639

Electrolyte replacement for patients on cytotoxic chemotherapy regimens for malignant disease

35

0

1641

Therapeutic phlebotomy for patients with polycythemia rubra vera or haemochromatosis

36

0

1642

Isolated limb perfusion including exposure of major limb artery and vein, arteriotomy and venotomy

358

154

1645

Intracaviatory insertion with radioactive source (cranium, chest, abdomen )

215

69

1646

Plasmapheresis.

36

0

1657

Cytotoxic chemotherapy (combination therapy), infusion, for (a) initial day's treatment for a new patient, (b) first day's treatment of a new cycle of therapy, for an established patient, day care or in-patient.

52

0

1658

Succeeding days of cytotoxic chemotherapy (combination therapy) infusion treatment after the first day's treatment, day care or in-patient.

35

0

1663

Drainage of abscess or haematoma, (deep tissues) requiring general anaesthetic

72

38

4281

Bone marrow aspiration

36

38

Diagnostic

4282

Bone marrow biopsy

54

38

Diagnostic

4287

Bone marrow aspiration and biopsy

72

38

Diagnostic

4283

Allogeneic bone marrow transplantation, benefit includes all procedures and in-patient care

609

0

4284

Autologous bone marrow transplantation, benefit includes all procedures and in-patient care

501

0

4286

Bone marrow harvesting

107

69

I.P.

4288

Peripheral blood stem cell harvesting

107

0

I.P.

4291

Peripheral blood stem re infusion, benefit includes cytotoxic chemotherapy and in patient care

501

0

EAR, NOSE AND THROAT

EAR: (See also Plastic Section)

1665

Atresia of auricle, 2 or 3 stages, correction of (per stage)

251

69

I.P.

1666

Attico antrostomy, unilateral

358

107

1670

Ear polyp, excision of Ear toilet requiring use of operating microscope and micro

54

38

1671

inspection of tympanic membrane with or without general anaesthesia, unilateral or bilateral

54

38

I.P.

1675

Drainage external ear, abscess or haematoma

54

69

1680

External auditory canal excision of tumour

107

54

1685

External auditory canal removal of exostosis or osteoma

107

69

1686

Reconstruction of external auditory canal (meatoplasty) (e.g, for stenosis due to trauma, infection)

212

69

I.P.

1690

Facial nerve decompression (in temporal bone)

358

107

1695

Facial nerve graft (in temporal bone)

394

107

1700

Removal of foreign body from ear, under general anaesthetic

72

38

I.P.

1701

Labyrinthectomy; transcanal

266

92

1710

Mastoidectomy, radical with or without labyrinthectomy

358

107

1715

Mastoidectomy, simple

305

69

1730

Myringoplasty

251

92

I.P.

1735

Myringotomy

36

38

1740

Myringotomy (bilateral)

72

38

1741

Removal of drain tube(s) under general anaesthetic

36

38

1751

Pinna, total excision

144

54

1752

Pinna, partial excision with flap reconstruction

215

69

1753

Pinna, partial excision and graft

144

54

1755

Preauricular sinus, excision of

144

54

1760

Saccus endolymphaticus for Meniere's Disease

322

107

1765

Sebaceous cyst of ear, removal of

54

38

1770

Stapedectomy

430

92

1771

Stapedectomy with plastic reconstruction of ossicles

430

107

1790

Tympanoplasty

394

92

I.P.

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

5980

Combined approach tympanoplasty

466

107

1785

Myringotomy with insertion of grommet

107

42

1786

Myringotomy, bilateral, with insertion of grommets

161

54

1796

Electrocochleography

22

38

Diagnostic

NOSE:

1800

Epistaxis anterior packing and/or cautery

72

38

I.P.

1805

Epistaxis posterior anterior packing and/or cautery

107

38

I.P.

1810

Epistaxis anterior ethmoid and/or internal maxillary ligation

144

54

I.P.

1815

Foreign body, removal under general anaesthetic

36

38

1820

Polypectomy, single

36

38

I.P.

1825

Polypectomy, multiple

107

38

I.P.

NOSE and ACCESSORY SINUSES:(See also Plastic Section)

1830

Accessory sinuses, open operations on, unilateral (including Caldwell Luc)

179

54

1840

Accessory sinuses, open operations on, bilateral (including Caldwell Luc)

268

69

1850

Antral biopsy

36

38

Diagnostic

1855

Antral puncture (antrotomy) and washout unilateral

72

38

I.P.

1860

Antral puncture (antrotomy) and washout bilateral

107

38

I.P.

1865

Antral lavage involving insertion of polythene tube (unilateral)

107

38

1870

Antral lavage involving insertion of polythene tubes (bilateral)

144

42

1875

Sinusotomy with or without biopsy, with mucosal stripping or removal of polyp(s)

107

54

1880

Nasal/Sinus endoscopy, surgical, with antrostomy (unilateral)

89

54

I.P.

1885

Nasal/Sinus endoscopy, surgical, with antrostomy (bilateral)

144

54

I.P.

1890

Repair of choanal atresia, intranasal

144

54

1895

Repair of choanal atresia, transpalatine

322

92

1896

Crawford tube insertion, unilateral

72

38

1897

Crawford tube insertion, bilateral

107

38

1900

Ethmoid area malignant tumour excision

179

92

1905

Nasal/Sinus endoscopy, with or without biopsy, polypectomy or debridement

72

54

I.P.

Diagnostic

1910

Ethmoidectomy extranasal (unilateral)

144

69

1915

Ethmoidectomy extranasal (bilateral)

215

92

1920

Ethmoidectomy intranasal (unilateral)

144

54

1925

Ethmoidectomy intranasal (bilateral)

198

69

1935

External frontal sinus exploration

358

69

1940

External frontal sinus operation for malignant disease

430

107

1945

External rhinotomy (with drainage of ethmoid frontal, or maxillary sinuses)

358

92

1968

Nasal septum insertion of prosthetic button

89

38

1969

Plastic repair of nasal septum

251

92

1970

Nasal septum, submucous resection of

144

54

1980

Naso pharyngeal tumour, excision of

430

223

1985

Oro antral fistula, closure of

358

54

1990

Cauterisation and/or ablation, mucous of turbinates, unilateral or bilateral, any method, superficial

72

38

I.P.

1992

Nasal/Sinus endoscopy, surgical with ethmoldectomy (partial or total)

205

92

1993

Nasal/Sinus endoscopy, surgical with frontal sinus exploration with or without removal of tissue from frontal sinus

228

92

1745

Nostril closure for atrophic rhinitis

144

54

4525

Rhinoplasty

322

92

I.P.

5975

Rhinoplasty, primary, including major septal repair

358

92

THROAT:

1995

Abscess (retropharyngeal), incision and drainage (internal pharyngotomy)

72

54

1996

Bronchoscopy with bronchoalveolar lavage (includes irrigation of bronchial tree)

72

0

Diagnostic

1997

Bronchoscopy with transbronchial biopsy of lung

144

40

Diagnostic

2003

Bronchoscopy with combined bronchial and/or transbronchial biopsies and bronchoalveolar lavage

147

40

Diagnostic

1999

Bronchoscopy with laser ablation/ resection of tumour

215

69

2000

Bronchoscopy with brachytherapy or placement of radium source

215

69

2001

Bronchoscopy with selective bronchography

107

40

I.P

Diagnostic

2002

Bronchial provocation testing (histamine, methacholine etc.)

144

0

I.P.

Diagnostic

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

2011

Bronchoscopy with or without bronchial biopsy

72

40

I.P.

Diagnostic

2012

Bronchoscopy with or without bronchial biopsy (less than 2 years old)

92

54

I.P.

Diagnostic

2020

Bronchoscopy with removal of foreign body (includes foreign body removal by rigid endoscopy)

72

54

I.P.

Diagnostic

2030

Laryngoscopy

54

38

I.P.

Diagnostic

2040

Laryngectomy, all forms including vertical hemi laryngectomy and tracheostomy

501

200

2045

Larynx, microsurgery of

215

69

2050

Laryngofissure, external operation on

358

69

2055

Lateral pharyngotomy

287

69

2056

Direct operative laryngoscopy with operating microscope with or without biopsy, removal of foreign body, removal of lesion etc.

215

54

I.P.

2057

Vocal cord augmentation (injection of teflon)

161

54

2060

Oesophagoscopy

54

38

I.P.

Diagnostic

2065

Oesophagoscopy with biopsy and dilatation

89

54

I.P.

Diagnostic

2070

Oesophagoscopy with removal of foreign body

54

54

I.P.

2074

Upper G.I. endoscopy with oesophageal dilatation and lasertherapy

179

54

2075

Operative peroral endoscopy (including biopsy of larynx, trachea, bronchus, pharynx or oesophagus)

54

54

I.P.

2077

Oesophageal dilation and insertion of endoprosthesis

179

69

2079

Oesophagoscopy with multiple injection of oesophageal varices

107

69

5840

Oesophageal motility study

54

69

Diagnostic

2080

Papilloma or cyst of larynx, excision of

144

107

2081

Balloon dilatation of the oesophagus (includes endoscopy)

111

54

2085

Pharyngeal pouch or diverticulum, excision of

394

69

2090

Pharyngeal pouch or diverticulum endoscopic diathermy division

251

69

2096

Drainage and marsupialisation of cyst

161

54

2100

Pharyngolaryngectomy

538

261

2115

Incision and drainage, abscess; retropharyngeal or parapharyngeal

36

69

2125

Tonsils and/or adenoids (adults), removal of

161

54

2130

Tonsils and/or adenoids, removal of (children under 12 years)

126

54

2131

Tonsils or tonsils and adenoids, arrest of haemorrhage requiring general anaesthetic, following removal

89

54

2132

Tracheoesophageal puncture and insertion of prosthesis

126

54

2136

Transtracheal aspiration

72

0

Diagnostic

OTHER PROCEDURES:

2126

Overnight oximetry

36

0

Diagnostic

2133

Kveim test including follow up punch biopsy of skin

52

0

Diagnostic

2134

Kveim test including follow-up ellipse biopsy of skin

70

0

Diagnostic

2137

Mantoux test, injection and follow up interpretation

52

0

Diagnostic

5895

Full pulmonary function studies carried out in a pulmonary function laboratory including report Prolonged post-exposure evaluation of bronchospasm after

70

0

Diagnostic

2141

exercise, with multiple spirometric determinations as in 5895 including measurement of thoracic gas volume and expired gas determinations

79

0

Diagnostic

2139

Full sleep study (polysomnography)

139

0

Diagnostic

GYNAECOLOGICAL OPERATIONS

CERVIX:

2140

Cervix, amputation of

72

54

I.P.

2145

Cervix, biopsy of

36

38

I.P.

Diagnostic

2146

Cervix, cone biopsy of

72

54

I.P.

Diagnostic

2150

Cervical polypi, removal of

36

38

I.P.

2155

Cervix, dilatation of

36

38

I.P

2160

Cervix, local excision of lesion of

36

38

I.P.

2170

Cervix, suture of

54

38

I.P.

2171

Cervical cerclage

72

38

2175

Cervix, cautery of

36

38

I.P.

2180

Cervix, examination under anaesthesia

36

38

I.P.

Diagnostic

2181

Colposcopy

36

38

I.P.

Diagnostic

2182

Colposcopy and biopsy including Lletz procedure and/or laser therapy

54

38

Diagnostic

OBSTETRICAL:

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

2185

Caesarean hysterectomy

430

131

2190

Caesarean section (grant In aid for obstetrician's fees) Ectopic pregnancy, surgical management (laparoscopic or open):

207

92

2200

salpingectomy and/or salpingo oophorectomy (unilateral or bilateral)

179

92

2205

Hydatidiform mole (hysterotomy)

144

92

2206

Vaginal delivery (grant in aid)

137

0

2207

Epidural anaesthesia for vaginal delivery

0

96

UTERUS and ADNEXA:

2215

Aldridge sling operation

144

69

2220

Broad ligament, excision of cyst of

144

69

2225

Dilatation and curettage (diagnostic or therapeutic) Microsurgical repair of extensive tubal and peritubal disease

54

38

I.P.

2235

consequent on pelvic inflammatory disease and endometriosis including re-implantation of fallopian tube, unilateral Microsurgical repair of extensive tubal and peritubal disease

215

69

2240

consequent on pelvic inflammatory disease and endometriosis including re-implantation of fallopian tubes, bilateral Surgical repair of extensive tubal and peritubal disease consequent

322

92

2241

on pelvic inflammatory disease or endometriosis, unilateral or bilateral

228

69

2248

Hysteroscopy

54

38

2249

Transcervical endometrial resection

358

92

2250

Total abdominal hysterectomy Radical abdominal hysterectomy, with bilateral total pelvic

287

92

2255

lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)

484

131

2256

Total vaginal hysterectomy combined with anterior and posterior pelvic floor repair

466

92

2257

Total abdominal hysterectomy with unilateral or bilateral salpingo oophorectomy

466

92

2258

Resection of ovarian malignancy with total abdominal . hysterectomy, complete procedure

531

131

2259

Debulking of ovarian carcinoma with or without omenfectomy, complete procedure

380

131

2260

Sub total abdominal hysterectomy

287

92

2264

Total vaginal hysterectomy with urethropexy or urethroplasty

322

92

2265

Total vaginal hysterectomy

287

92

2267

Total vaginal hysterectomy and anterior or posterior pelvic floor repair

430

92

2270

Induction of radiation menopause

72

38

2273

Marlex sling procedure

144

69

2280

Myomectomy (multiple)

287

69

I.P.

2285

Myomectomy (simple, single)

251

69

I.P.

2289

Oophorectomy, unilateral or bilateral (complete or partial)

159

69

I.P.

2300

Ovarian cystectomy, unilateral or bilateral

179

69

I.P.

2319

Salpingectomy complete or partial, unilateral or bilateral

159

69

I.P.

2354

Salpingostomy or salpingolysis, unilateral or bilateral

228

69

I.P.

2364

Microsurgical tuboplasty (salpingostomy or salpingolysis), unilateral or bilateral

258

69

I.P.

2365

Salpingo oophorectomy, complete or partial, unilateral or bilateral

179

69

I.P.

2366

Salpingography and cannulisation for unblocking fallopian tubes, unilateral or bilateral

179

0

2370

Uterus, plastic reconstruction of

287

69

2375

Ventrosuspension/Gliliam's operation

144

69

I.P.

VULVOVAGINAL:

2380

Atresia vaginae, relief of (including dilatation of vulva and vagina)

107

90

I.P.

2385

Bartholin's gland cyst, excision of

54

38

2390

Bartholin's or Skene's gland, abscess of, incision and drainage

54

38

I.P.

2391

Burch colposuspension

215

92

2395

Caruncle, vulvovaginal, removal of

54

38

I.P.

2400

Colporrhaphy with amputation of cervix, anterior and posterior (Manchester or Fothergill operation)

287

69

2410

Colpotomy

107

69

2415

Cystocele, repair of

144

69

I.P.

2420

Cystocele and rectocele, repair of (including colpoperineorraphy)

179

69

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

2425

Cysts or simple tumours of the vulva or vagina, excision of

72

38

2430

Hymenotomy

54

38

I.P.

2435

Hymenectomy

54

54

2440

Perineal tear complete repair of

215

54

2441

Partial vaginectomy

358

92

I.P.

2445

Rectocele, repair of

179

69

I.P.

2450

Stress incontinence, Marshall Marchetti, urethropexy for

215

92

2460

Vaginal fistulae (recto vaginal), repair of

179

92

2465

Vaginal fistulae (vesico vaginal), repair of

287

92

2470

Vaginal wall, suture of

107

54

2475

Vagina, plastic repair for dyspareunia

144

92

2480

Vulvectomy simple, without glands

287

92

2485

Vulvectomy radical, with glands

394

131

2486

Intracaviatory insertion of radioactive source, cervix, vagina or uterus

215

69

2484

Diagnostic laparoscopy with or without biopsy, with or without tubal irrigation/insufflation

108

69

I.P.

2488

Diagnostic laparoscopy with or without biopsy. This procedure also includes dilatation and curettage (diagnostic or therapeutic), with or without tubal irrigation/insufflation

146

69

I.P.

2487

Diagnostic laparoscopy with/without biopsy and one or more of: excision of lesions of ovary;pelvic viscera or peritoneal surface; diathermy of endometriosis;division of adhesions;puncture of cysts. With/without tubal irrigation/insufflation.

126

69

I.P.

2489

As 2487 but including dilatation and curettage (diagnostic/therapeutic)

171

69

I.P.

OPHTHALMIC OPERATIONS

CONJUNCTIVA:

2490

Conjunctival flap

72

38

2493

Conjunctivectomy

54

42

2495

Conjunctival graft

107

38

2498

Conjunctival tumour with or without graft

144

38

2496

Cryotherapy, unilateral

144

42

2497

Cryotherapy, bilateral

215

42

2500

Cyst/ Granuloma - excision of

54

38

2505

Foreign body - removal of, from conjunctiva

54

38

2520

Wounds, repair

72

54

2521

Symblepharon division

72

54

2526

Symblephora - division of (includes conjunctival graft)

144

69

2527

Conjunctival biopsy

54

42

ANTERIOR SEGMENT:

2522

Removal of foreign body from anterior chamber, magnetic

287

69

2523

Removal of foreign body from anterior chamber, non-magnetic

287

69

2524

Removal of implanted material from anterior chamber

287

69

2525

Paracentesis of anterior chamber of eye with or without diagnostic aspiration of aqueous

107

54

I.P.

2580

Paracentesis of anterior chamber of eye for hyphaema with or without irrigation and/or air injection

179

38

2585

Paracentesis/Saemisch section etc.

179

38

2586

Reform anterior chamber secondary to trabeculectomy or post cataract surgery

179

38

CORNEA and SCLERA:

2530

Corneal grafting - penetrating/lamellar

430

107

2531

Removal of sutures (late Stage) corneal/sclera

54

38

2532

Keratoprosthesis

440

69

2533

Epikeratophakia

440

69

2535

Corneal surface removed and EDTA application

72

38

2510

Pterygium removal

72

38

2511

Pterygium removal and conjunctival graft

144

42

2540

Comeal tattooing Ulcer/Recurrent erosion, surgical treatment/Cautery with or without

72

38

2548

pricking, with or without debridement, with or without cryotherapy - one or more treatments, per episode of illness

72

38

2546

Corneal scraping

72

38

2547

Corneal biopsy

72

38

2555

Corneal or scleral tumour, excision

179

69

2556

Perforating injury cornea and/or sclera not involving uveal tissue

179

54

2565

Perforating injury cornea and/or sclera with reposition or resection of uveal tissue

306

69

2566

Repair of scleral staphyloma with or without graft

430

69

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

2575

Foreign body, removal of, from cornea Keratotomy (Wedge resections, relaxing incisions etc; for the

54

38

2577

correction of abnormal refractive errors resulting from cataracts, corneal scars or post traumatic corneal astigmatism)

358

69

2579

Excimer laser therapy for corneal pathology, per course

215

54

EYELIDS:

2589

Biopsy of eyelids

54

38

Diagnostic

2590

Chalazion - incision and curettage, one or more

72

38

2591

Botulinum injection for blepharospasm or to induce ptosis

89

38

2595

Ectropion

144

42

2600

Entropion

126

38

2596

Blepharophimosis - for pathology (not cosmetic)

188

69

2605

Epilation trichiasis

40

38

2606

Cryo to lash/electrolysis/ Removal lash follicle per course of therapy

79

38

2610

Injury to eyelid - repair (superficial)

54

38

2611

Opening of tarsorrhaphy

54

38

I.P.

2615

Injury to eyelid - repair (deep)

144

42

2620

Lid papilloma

144

42

2625

Superficial dermoid or cyst - excision of

107

38

2626

Canthotomy

31

0

I.P.

2630

Tarsorrhaphy

107

42

GLOBE:

2635

Evisceration of eye

215

69

2640

Excision of eye plus implant

251

69

2645

Removal of intraocular foreign body

287

69

2660

Removal of eye

215

69

IRIS, CILIARY BODY and CHOROID OPERATIONS:

2680

Division of anterior synechiae

179

54

I.P.

2685

Cyclodialysis

251

69

2696

Cyclocryotherapy/Diathermy

251

54

2700

Goniotomy

287

69

2710

Iridectomy

179

54

2711

Pupil reconstruction post trauma, post surgery

287

69

2725

Iris tumour, removal

287

69

2726

Iris biopsy

179

54

I.P.

2740

Trabeculectomy/Drainage procedure

287

54

2741

Laser trabeculoplasty, one or more treatments

251

54

2845

Local resection of ciliary body or choroidal tumour

215

42

2742

Trabeculectomy and tubes, etc.

424

54

LACRIMAL APPARATUS:

2750

Canaliculus repair with or without tube

251

54

2755

Dacryocystorhinostomy with or without tubes

287

69

2756

Removal of D.C.R. tube

31

0

2760

Lacrimal abscess (dacryocystitis) incision

54

38

2761

Lacrimal sac, syringing and probing

72

38

2764

Intubation of nasolacrimal duct

287

54

I.P.

2766

Punctal closure with cautery or controller

54

38

2768

3 Snip operation of lacrimal punctum

72

38

2769

Correction of everted punctum: cautery only

54

38

2770

Lacrimal sac excision (dacryocystectomy)

287

54

2771

Lacrimal gland tumour excision

314

69

2772

Conjunctivo - dacryocystorhinostomy with Lester Jones tube

298

69

2775

Lacrimal sac. syringing

54

38

LENS:

2779

Repositioning of intraocular lens

215

69

I.P

2780

Intraocular lens insertion not associated with concurrent cataract removal (secondary)

215

69

2785

Capsulotomy, needling (surgical)

107

69

2786

Revision of cataract wound

118

69

2795

Lens extraction

376

92

2802

Cataract extraction plus insertion of artificial lens (includes phacoemulsfication, etc.) For cataract extraction operations, all forms, where only monitored

466

92

2803

anaesthesia care is given, the anaesthetic benefit payable is shown opposite

0

38

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

LASER / LIGHT COAGULATION:

2644

Argon or Diode laser or Xenon Arc - for treatment of retinal or choridal disease, glaucoma, one or more treatments YAG laser - for capsulotomy, pupil formation, iridectomy,

215

42

2647

membranectomy, ciliary body treatment, glaucoma, one or more treatments

215

0

2806

Argon laser therapy for pan -retinal photocoagulation of diabetic retinopathy (per course of therapy)

314

42

MUSCLES:

2870

Routine squint operation, horizontal, vertical or oblique

287

69

2871

Transposition surgery - Jansens, Hummelsheim, Knapp procedure

393

69

2872

Adjustment post strabismus operation

95

38

2873

Botulinum toxin injection to extraocular muscles

89

38

2874

Muscle biopsy

79

38

I.P.

ORBIT:

2890

Orbit, exenteration of

430

92

2895

Orbit, exploration of, including biopsy

215

54

2900

Orbit, removal of foreign body from

251

69

2905

Orbit, removal of tumour from (Kronlein's operation)

322

69

2910

Orbit, repair of fracture of

287

69

2911

Orbitotomy

440

92

2915

Orbit, repair of fracture of, with plastic implant

358

69

2912

Trans nasal wiring

354

69

2920

Radio Active Source application

144

42

POSTERIOR SEGMENT:

2665

Prophylactic therapy for retinal detachment

298

54

2506

Removal of silicone oil

322

69

2675

Repair of retinal detachment - retinopexy with scleral buckling, scleral resection or scleral implant, etc. (For diathermy, cryotherapy or photocoagulation, use 2665)

538

107

2676

Vitrectomy

538

107

MISCELLANEOUS:

2875

Retrobulbar, orbital floor, subconjunctival, subtenons and facial nerve injections

54

69

I.P.

2880

Examination of eye under general anaesthetic

54

38

I.P.

Diagnostic

2926

Fluorescein angiography

36

0

Diagnostic

DENTAL/ORAL SURGERY

2940

Dental cysts of maxilla or mandible

107

54

2950

Extraction of teeth (more than 6 permanent teeth) with or without alveolectomy

89

54

2980

Labial frenectomy with dissection of tissue

36

54

2985

Odontoma, excision of

89

54

3005

Root resection or apicectomy, single, with or without cyst removal and apical curettage

72

54

3010

Root resection or apicectomy, multiple, with or without cyst removal and apical curettage

107

69

3015

Reimplantation of tooth in socket with splinting

72

54

3020

Simple cysts or epulis, palate or floor of mouth, excision of

72

54

3025

Small tumours of dental origin, removal of, includes biopsy

54

54

3030

Tuberosities, reduction of

72

54

ORTHOPAEDIC OPERATIONS

HAND: (See also Plastic Section)

3035

Abscess or infected tendon sheath of palmar spaces, drainage of

54

38

3039

Synovectomy of metacarpophalangeal joints, (more than two joints) with release of ulnar intrinsic tendons

251

69

3040

Arthrodesis of joint

144

54

I.P.

3045

Arthroplasty using joint prosthesis single

144

54

3050

Arthroplasty using joint prosthesis two joints

215

69

3055

Arthroplasty using joint prosthesis more than two joints

322

75

3060

Bone tumours (benign), excision of

251

54

3070

Bursectomy

72

38

3075

Chondroma, excision of (multiple) with bone graft

251

69

3080

Chondroma, excision (single) with bone graft

179

54

3085

Exostosis, excision of

107

42

3095

Fracture of phalanges and/or metacarpals closed reduction

72

38

I.P.

3100

Fracture of phalanx single internal fixation

107

42

3105

Fracture of phalanges multiple internal fixation

179

69

3110

Ganglion of hand, surgical removal

107

38

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

3115

Manipulation for treatment of dislocation of metacarpophalangeal joint

36

38

I.P.

3120

Nail, removal of

36

38

3125

Nails, removal of all

72

38

3130

Application of plaster of Paris casts

36

38

I.P.

3135

Synovioma, excision of

107

54

3136

Tendon repair - flexor-double (hand)

246

69

3140

Traumatic amputation of finger - single - reconstructive operation

144

54

3145

Amputation of two or more fingers

287

69

3150

Trigger finger, correction of

72

54

3155

Whitlow incision and drainage

36

0

WRIST:

3159

Arthroscopy of the wrist

144

54

Diagnostic

3160

Arthrodesis, using bone graft

322

75

3165

Arthroplasty

358

75

3170

Aspiration, wrist joint

36

38

3175

Bone grafting operation on scaphoid

215

69

3176

Herbert screw fixation, scaphoid

189

69

3180

Carpal bone (lunate scaphoid trapezium), excision of

144

54

3181

Trapezial joint replacement

430

75

3185

Carpal tunnel, decompression

107

54

3190

Carpus or peri carpal dislocations, manipulation

107

42

3195

Corrective osteotomy of lower end of radius

215

69

3200

Dislocation open reduction of

215

54

3205

Fracture (Colles') internal fixation of

144

69

3210

Fracture (Colles') manipulation and plaster of Paris

89

54

3211

Fracture of distal radius, external fixation of

108

38

3215

Injection, wrist joint

36

0

I.P.

3220

Ganglion, removal of aspiration

36

38

3225

Ganglion, removal of surgical

107

38

3229

Intercarpal fusion

189

69

3230

Nerve block for pain control

36

0

3235

Nerve median and ulnar nerve repair of

358

69

3240

Nerve median or ulnar nerve repair of

287

54

3245

Radial styloid, excision of

107

69

3250

Sympathetic block

72

0

3255

Synovectomy of wrist joint

215

69

3260

Tendon repair at wrist single

144

54

3265

Tendons repair at wrist multiple

215

69

3270

Tendon transfer about the wrist, single

179

69

3271

Tendon transfer about the wrist, multiple

268

92

3275

Ulna, lower end of (malunited Colles), excision of

107

69

3276

Smith's or Barton's fractures, internal fixation of

201

69

FOREARM and ELBOW:

3280

Amputation through forearm

377

69

3285

Annular ligament, repair of

215

69

3290

Anterior capsulotomy and excision myositis ossificans

215

69

3295

Arthrodesis

358

69

3296

Arthroscopy, elbow, diagnostic, with or without synovial biopsy, removal of loose body or foreign body, synovectomy, debridement

144

54

3300

Arthroplasty

430

92

3305

Aspiration and injection forearm/elbow

36

38

I.P.

3315

Drainage of joint

72

42

3316

External fixation, upper limb

108

54

3320

Fracture forearm (complete) closed reduction and plaster of Paris

107

54

3325

Fracture forearm (greenstick) closed reduction and plaster of Paris

89

54

3330

Fracture about elbow, closed manipulation of

107

69

3335

Fracture dislocation, open reduction

287

69

3340

Fracture of forearm bones, open reduction of

358

69

3341

Open reduction, internal fixation and bone grafting (forearm & elbow)

417

92

3345

Fracture of lateral condyle, open reduction of

251

69

3350

Fracture of medial condyle, open reduction of

179

69

3355

Fracture (supracondylar), closed reduction of

107

54

3360

Fracture olecranon, screwing of

107

69

3365

Closed treatment of elbow dislocation

36

38

I.P.

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

3370

Nerve ulnar transplant

215

69

3375

Olecranon bursa, removal of

107

54

3380

Radius excision of head of

144

69

3381

Silastic interposition of radial head

265

69

3385

Synovectomy of elbow joint

287

69

3390

Tendon transplants about the elbow

179

54

3395

Tendon sheaths, removal of in forearm

179

54

3400

Tennis elbow advancement of extensor muscles

144

54

HUMERUS and SHOULDER:

3401

Arthroscopy, shoulder, surgical, with removal of loose body or foreign body, synovectomy, debridement

215

69

3402

Arthroscopic suture capsulorrhaphy for anterior shoulder instability

430

107

3403

Arthroscopy, shoulder, diagnostic with or without synovial biopsy

144

54

Diagnostic

3404

Acromioplasty

215

69

5875

Shoulder replacement prosthesis

430

107

3405

Acromio clavicular joint, excision of

144

69

3410

Acromio clavicular joint, open reduction of

215

69

3411

Arthroscopic subacromial decompression

228

69

3412

Arthroscopic excision outer end clavicle

189

69

3413

Arthroscopic excision outer end of clavicle/subacromial decompression

265

69

3415

Amputation through arm

287

69

3420

Arthrodesis, humerus/shoulder

430

92

3425

Aspiration of joint, humerus/shoulder

36

38

3430

Biopsy, synovial, humerus/shoulder

54

38

Diagnostic

3435

Capsulotomy (acute capsulitis)

107

54

3440

Disarticulation, humerus/shoulder

430

92

3445

Dislocation, open reduction, humerus/shoulder

358

69

3450

Dislocation, acute, manipulation under general anaesthetic, humerus/shoulder

54

38

3455

Dislocation recurrent operation for, humerus/shoulder

358

69

3464

Forequarter amputation

456

92

3465

Fractured clavicle, closed reduction

89

38

3470

Fractured clavicle, open reduction

215

69

3475

Fractured humerus, open reduction with internal fixation

287

69

3480

Fractured humerus, open reduction and bone graft

358

69

3485

Fractured humerus, closed reduction

107

54

3490

Injection of joint, humerus/shoulder

36

38

I.P.

3495

Manipulation of humérus/ shoulder under general anaesthetic

36

38

I.P.

3500

Repair of capsule (in rotator cuff injuries) humerus/shoulder

322

69

3509

Saucerising humerus in chronic osteomyelitis

228

69

3510

Subacromial bursectomy

251

69

3515

Tendon transplant about shoulder

251

69

SPINAL REGION:

3520

Anterior drainage of paravertebral abscess with bone graft

394

107

3521

Anterior release and fusion for scoliosis/kyphosis

759

261

3525

Antero lateral decompression

394

107

3526

Antero lateral decompression involving two or more levels

555

177

3530

Coccyx, excision of

215

54

3540

Epidural injection

89

0

I.P.

3541

Caudal injection

89

0

I.P.

3545

Epidural infusion with cannula

107

0

3550

Fracture or fracture dislocation of spine traction, reduction and plaster cast

394

92

3555

Fractured spine, open reduction of

394

177

3559

Chemonucleolysis for intervertebral disc

144

54

3560

Intervertebral disc, removal

251

92

3561

Needle aspiration of intervertebral disc

144

54

3563

Excision of thoracic intervertebral disc

538

200

3565

Laminectomy and exploration

358

92

3566

Neuralarch biopsy

92

38

3571

Posterior spinal fusion with instrumentation for scoliosis

759

261

3580

Spina bifida closure

358

69

3585

Spina bifida lumbar spinal osteotomy

358

107

3586

Spinal fusion, simultaneous combined anterior and posterior - one level, with instrumentation

759

261

3587

Spinal fusion, simultaneous combined anterior and posterior -multiple level with instrumentation

835

261

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

3588

Spinal fusion, simultaneous combined anterior and posterior fusion - one level without instrumentation

607

261

3589

Spinal fusion, simultaneous combined anterior and posterior fusion - multiple level, without instrumentation

759

261

3590

Spinal manipulation, under general anaesthetic

72

38

3592

External fixature of the spine

305

69

3593

Synthetic fusion (GRAF) one level

531

200

3594

Synthetic fusion (GRAF) two level

683

261

3598

Spinal fusion, multiple level, with internal fixation

759

261

3595

Spinal fusion

466

154

3596

Spinal fusion, in scoliosis spine, anterior and posterior

466

261

3597

Spinal fusion involving two or more levels

573

300

3600

Vertebral body biopsy

215

69

Diagnostic

3601

Spinal fusion, one level with instrumentation

501

261

3602

Removal of instrumentation

215

92

3603

Spinal stenosis decompression, one level

341

107

3604

Spinal stenosis decompression, two levels

380

107

SACRO - ILIAC JOINT REGION:

3605

Arthrodesis, sacro iliac joint

394

92

3610

Aspiration, sacro iliac joint

36

38

3615

Biopsy of sacro iliac joint region

54

38

Diagnostic

3620

Injection, sacro iliac joint region

36

38

I.P.

3625

Pelvic osteotomy (bilateral) in ectopia vesica

358

107

HIP and FEMUR:

3630

Acetabuloplasty shelf operation

251

92

3631

Internal fixation of acetabular fractures

609

300

3635

Acute dislocation manipulation for

107

42

3636

Congenital dislocation of hip, E.U.A. and P.O.P.

92

38

3640

Acute dislocation or fracture dislocation open reduction, hip/femur

358

107

3645

Above knee amputation

430

69

3650

Arthrodesis, hip/femur

501

92

3660

Arthroplasty of hip using prosthesis

430

107

3661

Revision of total hip arthroplasty, acetablar and femoral components with or without autograft or allograft

466

131

3665

Arthrotomy for loose body

287

69

3670

Colonna's arthroplasty

430

107

3675

Corrective osteotomy with or without internal fixation

358

107

3680

Curetting of greater trochanter and bursectomy

144

54

3685

Decompression operations or hanging hip operations

215

69

3690

Hind quarter amputation

501

154

3695

Drainage of hip joint for acute infection

144

54

3700

Exostosis of femoral neck in slipped femoral epiphysis, excision of

358

69

3705

Femoral condyle, osteotomy of

287

69

I.P.

3709

Fractured femur, hemiarthroplasty

430

107

3710

Fracture shaft of femur open reduction with internal fixation

358

69

3715

Fracture shaft of femur closed reduction with traction

144

69

3720

Fracture femur (supracondylar) open reduction of

358

69

3723

Fractured shaft of femur, closed intramedullary nailing

357

69

3724

Fractured shaft of femur closed intramedullary - interlocking nail

456

92

3725

Fracture of neck of femur intramedullary nail fixation of

322

69

3730

Fracture of femur (pertrochanteric or introchanteric) intramedullary nail fixation of

322

69

3731

Open treatment of anterior ring fracture and/or dislocation with internal fixation, (includes pubic symphysis and/or rami)

358

69

3732

Open treatment of posterior ring fracture and/or dislocation with internal fixation, (includes ilium, sacroiliac joint and/or sacrum)

471

154

3733

Pelvic fracture, external fixation

152

54

3735

Hip deformity, soft tissue operations for correction of

215

69

I.P.

3740

Injection or aspiration of the hip

36

38

I.P.

3745

Manipulation of hip closed, requiring general anaesthetic

36

38

3750

Open reduction and/or rotation osteotomy

358

69

3751

Open reduction, pelvic osteotomy and femoral shortening

501

92

3755

Pelvic osteotomy

430

92

3756

Modified innominate osteotomy including bone graft

501

92

3760

Pseudoarthroplasty of hip (Girdlestone operation)

322

107

3765

Slipped femoral epiphysis intramedullary nail, fixation of

322

69

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

3770

Slipped femoral epiphysis lower end stapling of

215

69

3775

Synovectomy of hip joint and debridement

322

69

3785

Transplantation of psoas muscle to greater trochanter (Mustard's or Sherrard's operation)

322

92

KNEE and LOWER LEG:

3790

Below knee amputation

322

69

3795

Arthrodesis, knee

358

69

3810

Aspiration, knee/lower leg

36

38

3815

Baker's cyst excision of

215

69

3816

Bone transportation

305

69

3817

Removal of fixator device tibia

89

54

3819

Arthroscopy, knee, diagnostic, with or without synovial biopsy

126

54

Diagnostic

3820

Cartilage(s), removal of, knee

215

69

3821

Arthroscopy and removal of cartilage, knee

251

69

3822

Arthroscopy of the knee for removal of loose body or foreign body, synovectomy, debridement

198

69

5890

Ligament reconstruction at the knee joint

358

69

I.P.

5891

Ligament reconstruction of the knee joint using autogenous graft

358

69

I.P.

3825

Corrective osteotomy of tibia in region of knee

322

69

3830

Corrective osteotomy of tibia in region of ankle

251

69

3835

Cruciate ligaments repair

287

92

3836

Arthroscopic anterior cruciate ligament reconstruction

358

69

3837

Arthroscopic anterior cruciate ligament reconstruction and menisectomy

440

69

3838

Arthroscopic anterior cruciate ligament reconstruction and menisceal repair

471

69

3839

Arthroscopic menisceal repair

281

69

3840

Drainage of joint in acute infection

107

54

3845

Exploration of joint, knee/lower leg

179

54

3850

Fixed flexion of knee soft tissue operations for

287

69

3855

Fracture dislocation of knee joint, operations for

394

75

3860

Fracture of tibia (condylar) open reduction of

358

69

3865

Fracture of tibial shaft open reduction and internal fixation

358

69

3870

Fracture of tibial shaft closed reduction

107

69

3875

Injection of joint, knee/lower leg

36

38

I.P.

3880

Lateral ligaments, repair

251

69

3885

Manipulation under general anaesthetic, knee/lower leg

36

38

I.P.

3890

Osteochondritis dissecans Smillies operation for

144

54

3895

Patellectomy or open reduction of fractured patella

251

69

3900

Pre patellar bursa, removal of

144

54

3905

Plication of vastii, etc.

144

54

3910

Prosthetic replacement (total) of knee joint

430

107

3911

Revision of arthroplasty of knee joint with or without allograft one or more components

466

131

3912

Reconstruction of knee, (anterior cruciate)

358

69

3915

Quadriceps mechanism repair

251

69

3920

Slipped epiphysis, stapling of, or epiphysiodesis

287

69

3925

Slipped epiphysis (tibial and femoral combined) stapling of, or epiphysiodesis

358

69

3930

Slipped epiphyses (bilateral tibial), stapling of

287

69

3931

Slocum's or similar procedure

358

69

3935

Synovectomy

287

69

3940

Synovial biopsy, knee/lower leg

54

38

Diagnostic

3945

Tendon transplants about knee joint

287

69

3950

Transplant of tibial tubercle

287

69

ANKLE:

3955

Arthrodesis of ankle joint

322

92

3956

Arthroscopy, ankle, with or without removal of loose body or foreign body, with or without synovectomy, debridement

161

54

3957

Arthroplasty (ankle)

212

69

3960

Aspiration and injection, ankle

36

38

I.P.

3965

Fracture of medial or lateral malleolus (1st degree Pott's fracture) internal fixation of

215

69

3970

Fracture of posterior malleolus (with or without fracture of other malleolus) internal fixation of

251

69

3971

Fracture of medial and lateral malleolus - open reduction and internal fixation of

265

69

3975

Fracture Pott's closed reduction

144

69

3980

Synovectomy and debridement

251

69

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

3985

Synovial biopsy, ankle

54

38

Diagnostic

3986

Talar fracture, open reduction and internal fixation of

251

69

3990

Tendo achillis, elongation of

215

69

3995

Tendo achillis, repair of

287

69

4000

Tendon transplants about the ankle joint and foot (multiple)

287

69

4005

Tendon transplants about the ankle joint and foot (single)

215

54

4010

Traumatic fracture and dislocation, open reduction of

287

69

4015

Unstable ankle Watson Jones operation for

287

69

CONGENITAL TALIPES EQUINOVARUS:

4019

Astragalectomy

251

69

4020

Dwyer's Valgus osteotomy

215

69

4025

Manipulation and plaster fixation

54

38

4030

Manipulation and strapping

54

38

4035

Rotation osteotomy of tibia

287

69

4040

Soft tissue release

215

54

4045

Tarsal osteotomy

251

69

4050

Tendon transplant - single

215

54

4051

Tendon transplant - multiple

304

69

FOOT:

4060

Arthrodesis of all inter phalangeal joints (Lambrinudi) unilateral

215

69

4065

Arthrodesis of all inter phalangeal joints (Lambrinudi) bilateral

322

92

4070

Arthrodesis of first metatarso phalangeal joint

144

54

I.P.

4075

Arthrodesis triple, in all its forms

358

69

4080

Arthrodesis, pantalar

430

92

4085

Claw foot (Steindlar) muscle stripping operations for

144

54

4090

Exostosis of first metatarsal (unilateral), removal of

107

54

4095

Exostosis of first metatarsal (bilateral), removal of

144

54

4100

Flat foot involving joint fusion, operation for

215

69

4101

Flexor tenotomy, single (foot)

76

38

4102

Flexor tenotomy, multiple (foot)

113

54

4103

Fracture of hindfoot, internal fixation, unilateral

228

69

4104

Fracture of hindfoot, internal fixation, bilateral

341

69

4105

Fracture of phalanges and/or metatarsals (closed reduction)

72

38

I.P.

4110

Fracture of phalanx and/or metatarsal (single) internal fixation of

107

54

4115

Fracture of phalanges and/or metatarsals (multiple) internal fixation of

215

69

4120

Ganglion of foot, excision of

72

38

4125

Hallux valgus and follow up, other than simple removal of exostosis (unilateral) operation for

215

54

4130

Hallux valgus and follow up, other than simple removal of exostosis (bilateral) operation for

287

69

4135

Hammertoe unilateral, correction of

107

54

4140

Hammertoe bilateral, correction of

161

69

4145

Grice's operation, subtalar bone block

107

54

4150

Ingrowing toe nail hemiphalangectomy

107

54

4155

Avulsion of nail plate, partial or complete, simple

35

0

4160

Ingrowing toe nail, removal of nail and nail bed

107

54

4165

Injection and manipulation, foot

36

38

I.P.

4170

Laprau's operation to correct position of toe

107

54

4175

Metatarsal heads, excision of all, and plastic correction of sole (unilateral)

161

54

4180

Metatarsal heads, excision of all, and plastic correction of sole (bilateral) (Hoffman's)

251

75

4181

Metatarsal joint replacement with prosthesis

358

69

4182

Metatarsal osteotomy, unilateral

152

54

4183

Metatarsal osteotomies, bilateral

228

75

4184

Chevron osteotomy - single

228

69

4185

Os calcis, osteotomy of (Dwyer)

215

69

4190

Os calcis and bursa, posterior exostosis of (unilateral) removal of

144

54

4195

Os calcis and bursa, posterior exostosis of (bilateral) removal of

215

69

4200

Plantar fascia, excision or division of (unilateral)

144

54

4205

Plantar fascia, excision or division of (bilateral)

215

69

4210

Plantar warts, surgical excision, one or more (not local application, cryotherapy etc.)

52

38

4211

Plantar warts, one or more, local application, per complete course of therapy

11

0

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

4215

Stamm's operation, unilateral

287

69

4220

Stamm's operation, bilateral

322

92

4225

Talectomy

287

69

4230

Tarsal osteotomy

179

54

4235

Tendon transplantation about the foot, multiple

287

69

4240

Tendon transplantation about the foot, single

215

54

4245

Tendon transplantation flexor and extensor all toes, unilateral

322

69

4250

Tendon transplantation flexor and extensor all toes, bilateral

394

92

4255

Trans metatarsal amputation of foot

215

54

4260

Trans metatarsal amputation of one toe

107

38

4261

Trans metatarsal amputation of two or more toes

215

54

MISCELLANEOUS:

4264

Arthroscopy

72

54

Diagnostic

4265

Arthrotomy for removal of loose bodies

144

54

4270

Biopsy of tumour of long bones open

72

54

Diagnostic

4271

Costotransversectomy

205

54

4272

Excision of large malignant bone tumours for limb conservation

430

177

4273

Excision of large malignant bone tumours for limb conservation including prosthetic insertion

501

177

4275

Body plaster application

144

42

4280

Bone cysts excision

179

54

4285

Bursectomy large joints

144

75

4290

Chondroma removal

322

69

4295

Exostosis of long bones removal

144

54

4300

Fracture sternum and ribs operative reduction

179

92

4301

Limb lengthening (upper or lower limb) including osteotomy procedure and application of fixator devices

430

107

4305

Long bones, sequestrectomy, decortication or bone graft

322

69

4310

Osteomyelitis drilling of bones

161

54

4315

Osteomyelitis, marsupialisation and bone grafting

358

75

4320

Removal of plates, pins, screws, etc. (superficial)

89

54

4325

Removal of plates, pins, screws, etc. (deep)

215

69

4330

Trimming of stump following amputation of limb

107

54

PLASTIC SURGERY

(See also Orthopaedic, E.N.T.and General Sections) Benefit is not payable for cosmetic treatment except the correction of accidental disfigurement or significant congenital disfigurement.

BURNS:

4335

Burns and scalds, treatment under anaesthesia, second degree or more (depending on extent)

144

92

4340

Burns, over 10% body surface (equivalent of whole upper limb), excision and graft of

358

92

4350

Graft of extensive areas beyond 10%

430

92

4355

Graft of granulating areas less than 10%

179

54

4360

Major burns of face, excision and graft of

358

92

4365

Major burns of hands, excision and graft of

358

69

4370

Smaller areas, excision and graft of

215

54

BURNS - LATE DEFORMITIES:

4385

Inlay grafts (ankle)

287

54

4390

Inlay grafts (elbow)

179

54

4395

Inlay grafts (fingers)

179

54

4400

Inlay grafts (knee)

287

54

4405

Scar excisions (per scar) flexion, elbows, fingers, groin, knees

144

54

4410

Z plasty (per scar) flexion, fingers, elbows, groin, knees

144

54

CLEFT LIP and PALATE:

4415

Adjustment of lip margin

72

38

4420

Adjustment of scars, secondary

72

54

4425

Cleft palate reconstruction

287

92

4430

Complete cleft lip and anterior palate repair

358

92

4431

Primary repair, unilateral cleft lip

358

92

4432

Primary repair, bilateral cleft lip

376

92

4433

Secondary repair, unilateral cleft lip

358

92

4434

Secondary repair, bilateral cleft lip

376

92

4440

Fistula, secondary closure of

287

69

4460

Maxillary bone graft

358

107

4465

Nostril margin, secondary correction of

215

54

4466

Total cleft rhinoplasty

322

92

4470

Pharyngoplasty (not for snoring)

287

92

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

4475

Soft palate partial cleft, reconstruction of

251

69

BREAST RECONSTRUCTION:

4479

Nipple reconstruction

198

69

4480

Breast reduction

501

92

4481

Breast augmentation (implants)

198

69

4482

Plastic repair of inverted nipple

215

42

4483

Transverse flap (TAIF or TRAM), reconstruction of breast, post mastectomy

430

177

4484

Mastopexy including full thickness graft from other areas

358

107

4485

Breast reconstruction, vertical rectus flap, post mastectomy

412

177

4486

Breast reconstruction, latissimus dorsi flap, with or without implant, post mastectomy

340

69

4487

Breast reconstruction, other flap, with or without implant, post mastectomy

340

69

4488

Breast reconstruction, implant only, post mastectomy

126

54

TISSUE EXPANDERS:

4551

Insertion of expander including any subsequent injections of expander

322

69

4552

Removal of expander

107

54

4553

Removal of expander and inserting of expanded skin

233

69

EYELIDS:

4490

Eyelid bags, repair of

251

54

FACIAL TRAUMA:

4489

Facial trauma, suturing of facial nerve

287

75

4491

Facial trauma, suturing of facial nerve branch

251

69

4492

Facial trauma, grafting of facial nerve, sural nerve, greater auricular nerve

358

92

FACIAL TUMOURS:

4493

Excision of facial nerve and graft, sural nerve, greater auricular nerve

412

92

DELAYED FACIAL REANIMATION - SKIN and DERMAL HITCHES:

4494

Wedge excision of lower lip

251

75

4496

Nasolabial skin/dermal hitch

179

69

STATIC SLINGS:

4497

Temporalis fascial sling, oral, nasolabial, ocular

466

154

4498

Orbicularis oris hitch

466

154

DYNAMIC SLINGS:

4499

Masseter to oral angle, digastric to lower lip or temporalis to fascial slings

466

154

NERVE TRANSFERS:

4500

Facial nerve graft (in face) (see E.N.T. operations for facial nerve graft in facial canal

430

107

4501

Cross facial nerve grafting, hypoglossal/facial nerve reanimation

609

223

COMPLEX FREE TISSUE TRANSFER:

4502

Free muscle transfer, pectoralis minor, gracilis or extensor digitorum brevis as a second stage to 4501

609

223

4510

Facial reanimation in facial paralysis (unilateral)

466

107

OTHER PROCEDURES:

4520

Moles or cysts, excision and suture (Plastic)

72

54

4530

Facial scars, dermabrasion, per scar

72

38

4535

Scars on face excision or Z plasty (3 or more)

251

69

4540

Scars on trunk excision or Z plasty

251

69

4545

Wounds of face suture (per wound)

72

38

EAR:

4555

Accessory auricles, removal

72

38

4560

Epithelioma of ear, excision and reconstruction, lobule placement

144

54

4561

Cartilage graft(s), reconstruction of ear

322

75

4562

Ear reconstruction, further minor procedures

144

54

4575

Protruding ears correction with reconstruction of folds (bilateral)

268

69

4580

Protruding ears, correction of with reconstruction of folds (unilateral)

179

54

EYES:

4585

Contracted socket

251

92

4590

Cyst of eyelids, excision of

72

38

4595

Enophthalmos bone graft

322

92

4605

Decompression, orbit

358

131

</

Code

Surgical Procedure

Procedure Benefit IR£

Surgical

Anaesthetic

4610

Eyebrow graft

144

54

4615

Eyelids, repair of, for avulsion

144

54

4620

Eyelid, inlay grafts (one lid)

251

54

4625

Eyelid operations in facial paralysis

215

54

4630

Eyelid, total reconstruction of

358

69

4635

Muscle advancement for ptosis (unilateral)

268

69

4640

Naso lacrimal duct, reconstruction of

179

69

GENITO URINARY:

4645

Ectopia vesica (reconstruction of bladder)

358

154

4650

Ectopia vesica (reconstruction of urethra) (per stage)

179

92

4655

Epispadias, correction of dorsal curvature

215

69

4660

Epispadias, reconstruction of urethra

215

69

4665

Hypospadias, correction of ventral curvature or chordee

215

69

4670

Hypospadias, fistula closure

215

69

4675

Hypospadias, reconstruction of urethra

251

69

4676

One stage hypospadias or epispadias repair with or without chordee, urethroplasty with skin graft repair

555

107

4680

Urethra, plastic reconstruction of

287

69

4681

Insertion of Jonas penile prosthesis

215

69

4682

Insertion of inflatable (multi component) penile prosthesis, including placement of pump, cylinders and/or reservoir

305

92

4685

Urethra, second stage, reconstruction of

358

69

4686

Cliteroplasty

304

92

4690

Vaginal reconstruction with skin graft

358

92

4691

Young Dee's Leadbetter operation

538

177

HANDS:

4695

Congenital hand deformities reconstruction on each hand (per stage)

251

69

4700

Congenital hand deformities moderate repairs on each hand (per stage)

144

92

4705

Contractures extensive straightening of hand and inlay grafts

251

75

4710

Contractures, localised, division and graft

144

54

4711

Dermofasciectomy, removal of flexor, skin, full thickness skin graft including distal or full palm, one finger

287

92

4712

Dermofasciectomy, removal of flexor skin, full thickness skin graft including distal or full palm, one finger including simple fasciectomy to another finger

394

92

4715

Dupuytren's contracture fasciectomy (one or two fingers)

215

69

4720

Dupuytren's contracture fasciectomy (three or more fingers)

287

69

4721

Dupuytren's contracture, palm and fingers

304

69

4730

Injury to hand major multiple repair of tendons, nerves and skin

394

92

4735

Injury to hand, moderate, wound repair or graft

215

69

4740

Island grafting, for sensory loss, finger and/or thumb

394

92

4745

Neoplasm, major excision and repair with tendon grafts and flaps

430

92

4750

Neoplasm, localised excision and graft

215

69

4760

Nerve repair, primary, single or multiple

251

92

4765

Nerve repair in extensively scarred hand

358

92

4770

Opposition strut graft to thumb

287

69

4775

Palmar ganglion, compound, synovectomy of

287

69

4780

Policisation (finger replacement of lost thumb)

466

177

4785

Syndactyly, repair of (single)

287

69

4790

Syndactyly, repair of (multiple)

287

92