S.I. No. 84/1996 - Health Insurance Act (Risk Equalisation Scheme), 1996


S.I. No. 84 of 1996.

HEALTH INSURANCE ACT (RISK EQUALISATION SCHEME), 1996

The Minister for Health in exercise of the powers conferred on him by sections 3 and 12 of the Health Insurance Act, 1994 (No. 16 of 1994) hereby makes the following Scheme—

PART I GENERAL

1. This Scheme may be cited as the Health Insurance Act, 1994 (Risk Equalisation) Scheme, 1996.

2. Articles 3 to 6, 9 and 10 of this Scheme shall come into operation on the 28th day of March 1996.

Articles 7 and 8 shall come into operation on a day determined in accordance with article 10.

3. In this Scheme—

"the Act" means the Health Insurance Act, 1994 ;

"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;

"cell" means a group of fully insured persons who belong to both a common gender and a common prescribed age band;

"cell day-patient days" has the meaning assigned to it in Schedule D of this Scheme;

"cell equalised benefits" has the meaning assigned to it in Schedule D of this Scheme;

"cell weighted claim value" has the meaning assigned to it in Schedule D of this Scheme;

"claim" means an application by, or on behalf of, a fully insured person to a registered undertaking for the discharge or reimbursement under the terms of a health insurance contract of all or part of the fees or charges due to a health services provider in respect of:

(a) the provision of prescribed health services during a hospital stay: or

(b) the provision of the prescribed health services listed in Table C.2 of Schedule C while that person was in receipt of out-patient services;

"corrective payment" means a payment made to, or an amount recovered from, a health services provider or an insured person in respect of prescribed health services for which an incorrect payment, other than one arising from a systematic error in the method of processing claims, has been made;

"covered persons" has the meaning assigned to it in Schedule D of this Scheme;

"day-patient day" means a day, including a day upon which an in-patient 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 who is discharged as scheduled;

"data adjustment" has the meaning assigned to it in article 6 of this Scheme;

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

"equalisation contribution" has the meaning assigned to it in Schedule D of this Scheme;

"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 ;

"the fund" means the risk equalisation fund;

"gross provider payment" means, in respect of a settled claim, a payment or payments, based on proper and correct accounts, due or nominally due from a registered undertaking to a health services provider or in respect of services rendered by that provider disregarding the effect of

(a) any third party recoveries made in respect of that claim;

(b) any corrective payments in respect of that claim; and

(c) any discounts, overall limits or like reductions or bonuses or other additional compensation which may have been agreed between that provider and that undertaking;

"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;

"hospital stay" means an in-patient stay or a day-patient day;

"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;

"market equalised benefits (total)" has the meaning assigned to it in Schedule D of this Scheme;

"net provider payment" has the meaning assigned to it in article 5 of this Scheme;

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

"prescribed age band" means one of the following age groupings

(a) age 17 and under

(b) age 18 to age 29

(c) age 30 to age 39

(d) age 40 to age 49

(e) age 50 to age 59

(f) age 60 to age 69

(g) age 70 to age 79

(h) age 80 and over

where age is attained age (in whole years) of the person;

"prescribed equalised benefit" has the meaning assigned to it in article 5 of this Scheme;

"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 this Scheme;

(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 dependant 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 patient having been referred to the health services provider by 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;

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

"quarterly return" has the meaning assigned to it in article 6 of this Scheme;

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

"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;

"risk equalisation fund" has the meaning assigned to it in article 8 of this Scheme;

"scheme commencement day" has the meaning assigned to it in article 10 of this Scheme;

"scheme undertakings" has the meaning assigned to it in article 10 of this Scheme;

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

"settled accommodation claim" means a settled claim under which all or part of the payments relate to the discharge or reimbursement of fees or charges due to a private hospital or a publicly funded hospital in respect of a hospital stay except that a settled claim shall not be so designated if a previous settled accommodation claim relates to the same hospital stay;

"settled claim" means a claim in respect of which payments due have been made;

"settled hospital claim" means a settled accommodation claim or a settled out-patient claim;

"settled out-patient claim" means a settled claim which is not a settled accommodation claim and under which all or part of the payments relate to out-patient services except that a settled claim shall not be so designated if a previous settled out-patient claim relates to out-patient services provided on the same day;

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

"special procedure" means a procedure which is listed in Schedule B of this Scheme;

"third party recovery" means a payment made 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;

"undertaking equalised benefits" has the meaning assigned to it in Schedule D of this Scheme.

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

PART II DETERMINATION OF BENEFITS TO BE EQUALISED

5. (1) Each scheme undertaking shall calculate and record in respect of each settled claim the amount of prescribed equalised benefits in accordance with the provisions of this article and, where appropriate, the Schedules to this Scheme.

(2) In respect of each settled claim and for each health services provider the undertaking shall determine an amount (herein referred to as the "net provider payment") being the gross provider payment in respect of that claim and that provider multiplied by an amount determined in accordance with the formula

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where, for the quarter in which that claim was settled,

A is the sum of-

(i) the total of actual amounts which that undertaking has paid or is liable to pay, disregarding the effect of any corrective payments and third party recoveries, in respect of all settled claims which acquired that status during that quarter; and

(ii) the net total of corrective payments relating to that undertaking during that quarter provided that this amount shall not exceed 0.5% of B and shall not be less than -0.5% of B

reduced by the total of third party recoveries made by that undertaking during that quarter

B is the sum of that undertaking's gross provider payments under all settled claims which acquired that status during that quarter.

(3) The prescribed equalised benefits in respect of each settled claim shall be the sum of net provider payments under that claim subject in each case to a maximum limit determined, as appropriate, in accordance with Schedule A (payments in respect of hospital charges (in-patient, day-patient and out-patient)), Schedule B (payments in respect of hospital charges relating to special procedures) or Schedule C (payments in respect of consultants' fees (in-patient, day-patient and out-patient)) as amended from time to time.

PART III SPECIFICATION OF RETURNS

6. (1) Each scheme undertaking shall make a return (to be known for the purposes of this Scheme as the "quarterly return") in accordance with sub section 4 of section 12 of the Act and shall submit a copy of the report of the auditor specified in subarticle (4) in conjunction with the return.

(2) The first quarterly return to be made by a scheme undertaking shall be in respect of the quarter ending on 30th day of June, 1996 in the case of an undertaking which was registered on the date this Scheme comes into operation and shall be, in the case of an undertaking first registered after the date this scheme comes into operation, in respect of the quarter next following that first registration.

(3) The quarterly return shall be in the format set out in Schedule E and shall contain the details specified herein in respect of each cell and separately in respect of all cells combined—

(a) the number of fully insured persons on the first day of that quarter;

(b) the number of fully insured persons on the first day of the next following quarter;

(c) the cell equalised benefits for that quarter;

(d) the cell weighted claim value for that quarter;

(e) the cell day-patient days for that quarter;

(f) the total number of settled accommodation claims which acquired that status during that quarter in respect of covered persons and the number of those claims which relate to each of the following-

(i) one in-patient day only

(ii) two in-patient days only

(iii) three in-patient days only

(iv) four in-patient days only

(v) five in-patient days only

(vi) six in-patient days only

(vii) seven in-patient days only

(viii) eight in-patient days only

(ix) nine in-patient days only

(x) ten in-patient days only

(xi) not less than eleven and not more than fifteen in-patient days

(xii) not less than sixteen and not more than twenty in-patient days

(xiii) not less than twenty-one and not more than thirty in-patient days

(xiv) thirty-one or more in-patient days.

(g) the total number of settled out-patient claims which acquired that status during the quarter in respect of covered persons.

(4) Each quarterly return for each scheme undertaking shall be confirmed by two officers of that undertaking who are authorised to sign its accounts under the Companies Acts 1963 to 1990, or otherwise, and shall be audited by a qualified auditor to be appointed by the undertaking.

(5) If a scheme undertaking detects or otherwise becomes aware of an error in a quarterly return which has been made under this Scheme, other than errors which have previously been taken into account as corrective payments in the calculation of a net provider payment under article 5(2), it shall

(a) immediately notify the Authority or the person engaged under sub section 5 of section 12 of the Act; and

(b) within 15 days submit a corrected quarterly return to be known for the purposes of this Scheme as a data adjustment together with a report setting out the reason the error occurred and the steps which have been taken to prevent a recurrence.

PART IV DETERMINATION OF PAYMENTS

7. (1) "contribution" has the meaning assigned to it in subarticle (6);

"current quarter" has the meaning assigned to it in sub-article (3);

"first quarter" has the meaning assigned to it in subarticle (2);

"former equalisation contribution" has the meaning assigned to it in subarticle (4);

"prior quarter adjustment" has the meaning assigned to it in subarticle (5);

"revised equalisation contribution" has the meaning assigned to it in subarticle (4).

(2) Calculations to determine payments under paragraphs (a) and (b) of subsection (3) of section 12 of the Act shall be carried out by, or on behalf of the Authority, in respect of each quarter commencing with the quarter (referred to in this article as the "first quarter") next following the scheme commencement date.

(3) Not more than 30 days following receipt of a quarterly return as specified under article 6 of this Scheme for all scheme undertakings, the Authority shall determine, based on those returns, in respect of the corresponding quarter (referred to in this article as the "current quarter"), an equalisation contribution for each scheme undertaking in accordance with Schedule D.

(4) The Authority shall further, for each previous quarter in respect of which a new data adjustment has been submitted, determine for each scheme undertaking in accordance with Schedule D-

(a) the equalisation contribution for that quarter, based on the quarterly returns or the most recent previous data adjustments received for that quarter, increased by the addition of interest at a rate of 15 percent per annum for the period between the last day of that quarter and the last day of the current quarter (referred to in this article as the "former equalisation contribution"); and

(b) the equalisation contribution for that quarter, based on the information specified in paragraph (a) of this subarticle, but incorporating the newly submitted data adjustment, increased by the addition of interest at a rate of 15 percent per annum for the period between the last day of that quarter and the last day of the current quarter (referred to in this section as the "revised equalisation contribution")

provided that no such determination shall be made for any quarter before the first quarter.

(5) The prior quarter adjustment for the current quarter for each scheme undertaking shall be the sum, for each quarter in respect of which a new determination has been made under subarticle (4), of values determined in accordance with the formula

A - B

where

A is the revised equalisation contribution

B is the former equalisation contribution

(6) The contribution for the current quarter for each scheme undertaking shall be determined as the sum of—

(a) a value determined in accordance with the formula

0.25 x 1.04 x C

where C is the sum of its equalisation contributions for the current quarter and for the three quarters which immediately preceded the current quarter, provided that if an equalisation contribution has not been determined in respect of a quarter specified because that quarter precedes the first quarter then the equalisation contribution for that quarter shall be deemed to be zero; and

(b) that undertaking's prior quarter adjustment.

(7) If the contribution for a scheme undertaking is greater than zero then that amount shall be the payment by that undertaking to the Authority under paragraph (a) of subsection (3) of section 12 of the Act. The Authority shall notify that undertaking accordingly and shall specify in the notification the date on or before which the payment is to be made.

(8) Where a scheme undertaking fails to pay the amount due to the Authority in accordance with a notification under subarticle 7 that amount (or such part of that amount which from time to time remains unpaid) shall be increased by the addition of interest at a rate of 15 percent per annum computed from the day upon which that amount first became payable.

(9) If the contribution for a scheme undertaking is less than or equal to zero then the amount, if any, by which such contribution is less than zero shall be the payment to that undertaking from the Authority under paragraph (b) of subsection (3) of section 12 of the Act. The Authority shall notify that undertaking accordingly.

(10) In the circumstances specified in subarticle 8 the Authority may revise the payment or payments determined under subarticle 9 and notify the scheme undertakings affected accordingly.

PART V ESTABLISHMENT AND OPERATION OF RISK EQUALISATION FUND

8. (1) The Authority shall cause to be established and maintained a fund which shall be known as the risk equalisation fund (referred to in this Scheme as "the fund").

(2) (a) The fund shall be a current bank account which shall be managed and controlled by the Authority.

(b) Moneys payable into the fund shall be paid into the current account of the fund and moneys payable out of the fund shall be paid out of that account. Any interest accruing on moneys held in the account shall be paid out in direct proportion to current liabilities.

(c) (i) Payments due to the Authority under paragraph (a) of subsection (3) of section 12 of the Act shall be paid into the fund,

(ii) Payments due from the Authority under paragraph (b) of subsection (3) of section 12 of the Act shall be paid out of the fund.

(3) The accounts of the fund as audited by the Comptroller and Auditor General together with a copy of the report of the Comptroller and Auditor General thereon shall be furnished by the Authority to the Minister not later than 1 month following the completion of the said report.

PART VI EXEMPTED UNDERTAKINGS

9. Each registered undertaking which effects health insurance contracts which relate solely to one or both of the following—

(a) ancillary health services, or

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

shall be excluded from the application of articles 5 to 8 and 10 of this Scheme.

PART VII COMMENCEMENT OF RISK EQUALISATION SCHEME

10. (1) "scheme undertakings" means all registered undertakings excluding those restricted membership undertakings specified in paragraph (b) of sub section 2 of section 12 of the Act.

(2) Articles 7 and 8 shall come into operation with effect from the day (to be known for the purposes of this Scheme as "the scheme commencement day") notified by the Minister to all registered undertakings.

(3) The scheme commencement day shall be the last day of the period of six months next commencing after the last day of the first quarter in respect of which, if the scheme of risk equalisation had been in operation and calculations carried out in accordance with article 7 disregarding the proviso in paragraph (a) of subarticle 6 of that article, at least one of the following conditions would have been satisfied—

(a) the sum of payments by scheme undertakings under subarticle 7 of article 7, would have exceeded 2% of market equalised benefits (total); or

(b) (i) the amount payable to any one scheme undertaking under subarticle 9 of article 7 would have exceeded 2.5% of its undertaking equalised benefits or £125,000 if greater, and

(ii) the undertaking equalised benefits for that undertaking would have exceeded 5 % of market equalised benefits (total).

Schedule A

— Hospital Charges (In-patient, Day-patient and Out-patient Services)

1. The maximum prescribed equalised 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 (other than out-patient services) provided by a publicly funded hospital, to a fully insured person. Maximum prescribed equalised payments shall be determined as follows—

In respect of:

Maximum Prescribed Equalised 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 public 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 plus the amount of the public hospital daily inpatient 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 for each in-patient day of:(a) £250 for each in-patient day, or(b) 100% of(i) the charge made by the private hospital; less(ii) £20 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.

£250 for each day-patient day.

6.

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

£100 for each in-patient day.

7.

Prescribed health services which are out-patient services listed in Table C.2 of Schedule C provided by a private hospital other than a private psychiatric hospital.

£100 for each claim.

2. The amount determined under paragraph 1 in respect of hospital charges relating to childbirth by means of a normal vaginal delivery shall not exceed £300.

Schedule B

— Special Procedures

1. The maximum prescribed equalised 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 a fully insured person while that person is maintained in private hospital accommodation for in-patient services or day-patient services.

2. The maximum prescribed equalised payment shall be 90% of the procedure benefit derived from Table B.1 of this Schedule.

TABLE B.1

Procedure Code

Procedure Description

Procedure 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, Day-Patient and Out-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;

"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 the Schedule.

2. The maximum prescribed equalised payments in this Schedule relate to prescribed health services which are provided by a hospital consultant to a fully insured person while that person is in receipt of in-patient services, day-patient services or out-patient services.

3. The maximum prescribed equalised payment in respect of the participation by a consultant anaesthetist in a surgical or radiological procedure shall be 90% of the anaesthetic procedure benefit as set out in Table C.2 and C.3 respectively of this Schedule.

4. The maximum prescribed equalised payment in respect of in-patient attendance by a hospital consultant shall be 90% of the in-patient attendance benefit determined in accordance with Table C.1 of this Schedule.

5. The maximum prescribed equalised payment in respect of an in-patient consultation is £63 and arises when the admitting hospital consultant responsible for the care of an insured person refers that person to another hospital consultant for an opinion.

6. The maximum prescribed equalised payment in respect of a surgical procedure performed by a hospital consultant, other than a consultant anaesthetist, shall be 90% of the surgical procedure benefit as set out in Table C.2 of this Schedule.

7. The maximum prescribed equalised payment in respect of a radiological procedure performed by a consultant radiologist shall be 90% of the radiological procedure benefit as set out in Table C.3 of this Schedule or 90% of the surgical procedure benefit set out in Table C.2 of this Schedule as appropriate.

8. The maximum prescribed equalised payment in respect of a pathological procedure performed by a consultant pathologist shall be 90% of the procedure benefit as set out in Table C.4 of this Schedule.

Table C.1

Period of Attendance

In Patient Attendance Benefit

1 day

£ 73

2 days

£ 83

3 days

£ 94

4 days

£100

5 days

£107

6 days

£107

7 days

£122

8 days

£122

9 days

£135

10 days

£135

11 days

£148

12 days

£158

13 days

£168

14 days

£179

15 days

£189

Periods in excess of 15 days

£10 for each day in excess of 15 days plus £189

TABLE C.2

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

GENERAL SURGICAL OPERATIONS

ABDOMINAL WALL and PERITONEUM:

5

Abdominal wall, secondary suture of

148

123

15

Laparotomy, division of adhesions

260

133

20

Intra abdominal injury with rupture of viscus

441

256

25

Intra abdominal injury, multiple complicated with rupture of viscus

540

307

30

Laparotomy

196

123

35

Laparoscopy with or without biopsy

148

102

45

Omentopexy (otherwise)

196

154

50

Paracentesis abdominis

49

0

60

Pelvic abscess, drainage of

140

77

61

Percutaneous transabdominal biopsy

89

72

80

Peritoneum, drainage of

196

123

90

Laparotomy, intra-abdominal sepsis

392

184

5835

Peritoneal - venous shunt for ascites

392

184

ADRENAL GLANDS:

95

Adrenalectomy (unilateral)

450

205

100

Adrenalectomy (bilateral)

600

205

101

Adrenalectomy for phaeochromocytoma

600

512

105

Adrenal glands-any other operations

392

205

106

Neuroblastoma, tru cut biopsy

89

72

107

Neuroblastoma, resection

624

307

APPENDIX:

110

Appendicectomy (with or without complications)

196

123

GALL BLADDER and BILE DUCTS:

115

Cholecystojejunostomy

485

205

116

Choledochojejunostomy (Roux - en - Y)

593

205

117

Choledochoduodenostomy

431

205

118

Surgical repair of post-operative bilary stricture

1040

350

129

Hepaticojejunostomy

676

205

132

Cholecystectomy with exploration of common bile duct

540

205

135

Cholecystectomy (including laparoscopic method) and per operative cholangiogram

392

205

136

Percutaneous removal of gallstones from the bile ducts

245

123

140

Cholecystostomy with exploration, drainage or removal of calculus

295

143

145

Hepaticoduodenostomy

490

205

150

Transduodenal sphincteroplasty with or without transduodenal extraction of calculus

539

205

151

Transhepatic insertion of biliary endoprosthesis

294

154

152

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

245

143

153

Insertion of naso biliary tube and administration of CDC/URSO

245

102

GASTRIC OPERATIONS:

155

Antrectomy and drainage

490

184

165

Duodenal diverticula, excision of

441

184

175

Gastrectomy total or revision

638

256

180

Gastrectomy (sub total)

490

205

190

Gastroenterostomy

392

184

195

Gastroscopy or gastroduodenoscopy (fibroscope)

68

41

196

Upper G.I. endoscopy and biopsies

68

41

197

Upper G.I. endoscopy and polypectomy

68

41

200

Gastrostomy

294

123

201

Percutaneous gastrostomy

148

102

205

Gastrotomy/duodenotomy for haemorrhage

456

154

215

Oversewing perforated peptic ulcer

319

154

230

Rammstedt's operation

294

164

235

Stomach transection

490

256

240

Vagotomy and drainage or highly selective vagotomy

490

184

HERNIA:

245

Epigastric/Ventral hernia, repair of

196

113

246

Exomphalos, minor

312

123

247

Exomphalos, major

614

358

248

Exomphalos, delayed

614

358

250

Femoral hernia, repair of (bilateral)

368

164

255

Femoral hernia, repair of (unilateral)

245

113

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

270

Hiatus hernia, abdominal repair of

441

184

271

Laparoscopic repair of hiatus hernia

441

225

275

Hiatus hernia, transthoracic, repair of

441

225

280

Incisional hernia, repair of

392

123

285

Inguinal hernia, repair of (bilateral)

294

174

290

Inguinal hernia, repair of (unilateral)

196

123

291

Strangulated inguinal hernia, unilateral

275

123

295

Patent urachus, closure and repair of abdominal muscles

294

113

305

Recurrent hernia, repair of

294

143

310

Umbilical hernia, repair of

196

113

JEJUNUM and ILEUM:

320

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

228

123

331

Gastroschisis

728

358

355

Ileostomy

392

123

360

Intestinal obstruction (including bowel resection)

491

154

361

Intestinal atresia, single/multiple

491

236

364

Hydrostatic reduction of intussusception

196

123

370

Jejunostomy

196

123

385

Resection and anastomosis of jejunum or ileum

491

184

LARGE INTESTINE:

389

Anal canal EUA

45

72

390

Anal canal, plastic repair of (for incontinence)

294

143

395

Anal fissure, dilatation of anus for

49

72

396

Anoplasty for low anorectal anomaly

294

143

397

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

581

358

400

Lateral internal sphincterotomy

196

72

404

Parks' anal sphincter repair

581

358

405

Anal warts or papillae, removal of

74

72

410

Anus, excision of epithelioma of, with colostomy

392

205

415

Anus, excision of epithelioma of, without colostomy

74

82

420

Caecostomy

392

123

425

Caecostomy or colostomy, closure of

392

123

430

Colectomy, partial

491

184

435

Colectomy, total

664

307

436

Total colectomy and ileal pouch construction with temporary ileostomy

834

358

437

Closure of ileostomy

392

123

438

Total colectomy for toxic megacolon

785

358

450

Colonoscopy, one side

68

41

455

Colonoscopy, both sides

179

41

456

Colonoscopy plus polypectomy

89

41

457

Colonoscopy plus polypectomy full colon

179

41

458

Left colonoscopy and laser photocoagulation of rectum

148

41

459

Colonoscopy, full colon and laser photocoagulation of rectum

294

41

460

Colostomy

392

123

465

Resection of bowel and colostomy or anastomosis for diverticulitis

581

256

470

Faecal fistula, closure or resection

581

256

485

Fistula in ano, excision

245

123

490

Haemorrhoidectomy (external)

122

82

495

Haemorrhoidectomy (external, multiple)

148

92

500

Haemorrhoidectomy (internal)

215

123

506

Haemorrhoids, injection and/or banding

49

0

515

Imperforate anus, simple incision

49

82

520

Imperforate anus, with colostomy or pull through operation

392

225

525

Ischio rectal abscess, incision and drainage

148

92

513

Meconium ileus, open reduction with or without stoma

491

205

514

Meconium ileus reduction

148

154

516

Necrotising enterocolitis, percutaneous drainage

104

72

517

Necrotising enterocolitis, laparotomy resection/stoma

491

205

530

Proctoscopy or sigmoidoscopy

45

41

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

535

Proctoscopy or sigmoidoscopy, with biopsy

45

41

536

Diagnostic flexible sigmoidoscopy and biopsies

45

41

540

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

68

72

545

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

639

225

549

Delorme procedure

392

225

550

Prolapse of rectum, perineal repair

245

128

555

Rectal fistula, closure or repair

490

205

556

Balloon dilation of the rectum

99

72

560

Rectal or sigmoid polypi (removal by diathermy, etc)

148

82

565

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

686

358

570

Rectum, partial excision of

686

307

574

Presacral teratoma, excision

735

358

575

Rectum (combined synchronous resection)

735

358

576

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

431

123

577

Low anterior resection with coloanal anastomosis for cancer

834

358

578

Soave procedure

834

358

580

Sigmoid myotomy (Reilly's operation)

220

123

581

Sigmoidoscopy including dilatation of intestinal strictures

122

72

585

Stricture of rectum (dilation of)

49

72

590

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

490

236

LIVER:

595

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

314

184

600

Biopsy of liver (by laparotomy)

179

123

601

Transjugular liver biopsy

179

102

605

Biopsy of liver (needle)

89

77

610

Haemangioma of liver

196

225

611

Major liver resection

1196

512

612

Kasai type liver resection

624

307

616

Wedge resection of liver

323

307

617

Intrahepatic cholangioenteric anastomosis

780

307

618

Resection of hilar bile duct tumour

1196

512

619

Liver trauma

700

410

622

Insertion of hepatic artery catheter and reservoir pump

312

72

625

Left lateral lobectomy

834

358

630

Excision of hydatid cyst

431

307

MALE GENITAL TRACT:

635

Circumcision (over 6 years)

99

82

640

Circumcision (under 6 years)

99

82

645

Epididymectomy

196

113

650

Hydrocele (tapping)

49

67

655

Hydrocele, radical operation, bilateral

294

123

660

Hydrocele, radical operation, unilateral

196

102

665

Meatotomy

74

72

670

Orchidectomy, bilateral

196

102

675

Orchidectomy, unilateral

148

102

680

Orchidectomy with radical removal of lymph nodes

490

225

681

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

49

72

685

Penis, amputation of partial

245

123

686

Chordee release of

196

123

690

Penis, amputation of-with block dissection of glands

490

225

691

Transcatheter embolosation for relief of priapism

294

123

695

Prepuce, dorsal incision of

74

72

700

Prostatectomy

392

164

701

Radical retropubic nerve sparing prostatectomy (includes bilateral pelvic lymph adenectomy with bladder neck reconstruction and anastomosis to the urethra).

589

333

702

Transurethral microwave thermotherapy to the prostate (TUMT)

294

154

703

Insertion of an endo urethral stent for prostate obstruction

294

123

705

Spermatocele or spermatic cyst, (simple) excision of

196

113

706

Spermatocele or spermatic cyst, (multiloculate) excision of

196

113

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

710

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

343

184

711

Electro ejaculation procedure

99

72

715

Testicle, imperfectly descended, orchidopexy

148

102

720

Testicle, imperfectly descended bilateral orchidopexy

196

154

725

Testicle, imperfectly descended, associated with inguinal hernia

196

123

730

Testes, imperfectly descended, associated with bilateral inguinal hernia

294

184

735

Testes, unilateral orchidopexy and exploration of opposite side

294

143

740

Testicular biopsy (needle)

68

72

741

Testicular biopsy

134

77

742

Insertion of testicular prosthesis, unilateral

196

87

745

Reduction of torsion of testicle

99

82

749

Transcatheter management of varicocele, including testicular venography

245

123

750

Varicocele, bilateral removal

343

154

755

Varicocele, unilateral removal

245

123

760

Vasotomy or ligation of vas

99

72

765

Vas, reconstruction of (unilateral)

319

184

770

Vas, reconstruction of (bilateral)

441

225

PANCREAS:

771

ERCP sphincterotomy and extraction of stones

269

123

772

ERCP sphincterotomy and insertion of endoprosthesis

294

102

774

ERCP (endoscopic retrograde cholangiogram of pancreas)

224

123

775

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

915

512

776

Pancreatic biopsy

268

154

778

Pancreaticojejunostomy

639

307

780

Distal pancreatectomy

646

256

785

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

915

512

786

Simultaneous pancreas/kidney transplant

1008

563

790

Drainage of pancreatic abscess or pseudocyst

520

307

795

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

589

358

SPLEEN:

800

Splenectomy

392

184

806

Transcatheter ablation of function of spleen

294

128

807

Aspiration of splenic cysts

148

77

URINARY TRACT:

815

Aberrant vessels, division of

490

246

822

Permacath Hickman catheter for dialysis

245

123

823

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

29

0

824

Haemodialysis, chronic, in patient's home or at hospital out patient department, after completion of training sessions (minimum of three dialysis sessions per week inclusive of all consultant care) monthly benefit

184

0

825

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

122

0

826

Chronic haemodialysis (post shunt) 1st 12th treatment

49

0

827

Chronic haemodialysis (post shunt) 13th treatment onwards

49

0

828

Acute intermittent haemodialysis 1st 12th treatment

74

0

829

Acute intermittent haemodialysis 13th treatment onwards

74

0

830

Artificial kidney, use of (peritoneal dialysis)

122

0

831

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

49

0

832

Chronic peritoneal dialysis (hospital based after 12th day)

49

0

833

Peritoneal dialysis, chronic, in the patient's home or at hospital out patient department, after completion of training sessions (minimum of three dialysis sessions per week inclusive of all consultant care) monthly benefit

206

0

834

Tenchkoff catheter for CAPD dialysis

196

123

835

Bladder, implantation of radioactive source

245

92

836

Bladder, instillation of anticarcincgenic agent (BCG)

74

72

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

837

Continuous veno venous haemofiltration dialysis (CVVHD), per day

74

0

840

Bladder- rupture of (simple)

294

154

845

Bladder- rupture of (complicated traumatic)

392

256

850

Bladder neck, transurethral resection of

196

102

855

Bladder tumour, diathermy to, primary resection

294

102

860

Bladder tumour, repeat diathermy

99

77

865

Cystectomy, partial

343

154

870

Cystectomy, with re-implantation of ureters

490

307

875

Cystectomy with ileal or sigmoid loop and bowel anastomosis

662

358

876

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

735

358

877

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

834

358

880

Cystoscopy with or without biopsy

68

72

881

Cystoscopy and removal of JJ stent

148

72

885

Cystoscopy with intravesical operation (diathermy, etc.)

122

77

886

Therapeutic overdistension of the bladder

74

72

890

Cystoscopy with ureteric catheterisation including retrograde pyelography

89

82

895

Cystoscopy with removal of ureteric calculus

196

82

900

Cystoscopy with ureteric dilatation or meatotomy

148

82

905

Cystotomy

196

92

906

Augmentation cystoplasty (ileo caeco cystoplasty, colocystoplasty)

490

358

910

Diverticulum of bladder, excision or obliteration of

392

154

915

Embolisation of haemangioma of kidney

343

184

920

Hemi nephrectomy

343

205

923

Kidney transplant

686

410

924

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

294

123

925

Nephrectomy

441

205

926

Nephrectomy and caval extension below liver

540

225

927

Nephrectomy and caval extension of tumour above liver

712

358

928

Nephrectomy with caval invasion

809

410

930

Nephrolithotomy

490

184

931

Percutaneous nephrolithotomy, unilateral

294

205

932

Percutaneous nephrolithotomy, bilateral

441

205

933

Percutaneous nephrolithotomy, staghom

441

225

934

Percutaneous nephrostomy with or without antegrade pyelogram or stent placement

343

123

935

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

294

154

936

Percutaneous tract formation for renal stone removal

196

102

940

Pyelolithotomy

490

184

945

Pyeloplasty

540

184

950

Pyelotomy

294

154

955

Renal biopsy (needle)

89

72

956

Renal cyst puncture and aspiration

148

77

960

Suprapubic cystostomy

148

72

965

Suprapubic fistula, closure of

294

154

966

Transcatheter ablation of function of kidney

294

154

967

Transcatheter ablation of function of adrenal

294

154

970

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

392

184

975

Ureterolithotomy

294

143

980

Ureterolithotomy (bilateral)

441

134

981

Ureterolysis (unilateral)

392

143

982

Ureterolysis (bilateral)

589

184

984

STING procedure

294

82

985

Ureters, transplantation of, (bilateral)

589

184

990

Ureter, transplantation of, (unilateral)

441

164

991

Stamey Raz urethropexy

294

123

995

Ureterostomy (unilateral)

294

143

1000

Ureterostomy (bilateral)

441

184

1005

Urethral rupture of (straddle injury), repair of

294

133

1010

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

490

256

1015

Urethral dilatation

49

72

1020

Urethroscopy with treatment (diathermy)

99

72

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

1025

Urethrostomy

196

92

1030

Urethrotomy

99

72

1031

Complex urodynamic evaluation involving cineradiology

89

72

1032

Implantation of artificial urinary sphincter

490

225

1033

Whittaker test for evaluation of upper urinary tract obstruction

179

0

1035

Vesicolic fistula, closure of

392

184

5845

Ileal conduit urinary diversion

589

307

5850

Cystoscopy and ureteroscopy

179

92

5910

Lithotripsy, one or more sessions per hospital stay

294

92

5911

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

343

123

HEAD AND NECK

ARTERIES: (See also Neurological Section)

1041

Carotid body tumour greater than 4 cms

735

358

1042

Carotid body tumour less than 4 cms

540

358

CHEEK:

1045

Cyst or benign tumour of cheek or mouth, excision of

74

82

1050

Malignant growth of cheek, full thickness/wide excision of

392

154

1051

Malignant growth of cheek, superficial, excision of

172

123

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

1055

Cyst or benign tumour on lip, excision of

74

72

1058

Epithelioma of lip, lip shave

99

72

1059

Epithelioma of lip, wedge excision

196

77

1060

Epithelioma of lip, excision and flap reconstruction

392

184

NECK:

1065

Branchial cyst, pouch or fistula, excision of

392

184

1075

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

294

123

1080

Conservative neck dissection

392

225

1082

Radical neck dissection

468

256

1085

Thyroglossal cyst or fistula, excision of

392

184

1090

Torticollis, partial excision, open correction of

245

113

1095

Tuberculous caseous glands or sinuses, curettage of

104

77

PALATE: (See also Plastic Section)

1100

Laceration of palate, repair of

99

92

1105

Radical operation for malignant growth of palate

490

256

1104

Biopsy lesion of palate

47

72

MAXILLA:

1106

Partial maxillectomy including plastic reconstruction

520

256

1107

Total maxillectomy including plastic reconstruction

624

307

PARATHYROID GLANDS:

1110

Parathyroid adenoma, excision of

500

256

1111

Transcatheter ablation of function of parathyroid glands

294

154

1112

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

550

256

1113

Total parathyroidectomy with autotransplant or mediastinal exploration/intra-thoracic

650

256

1114

Parathyroid re-exploration

650

256

SALIVARY GLANDS:

1115

Abscess of salivary gland, incision and drainage

74

82

1120

Fistula of salivary duct, repair of

343

184

1125

Parotid or submandibular duct, dilatation of

49

82

1126

Submandibular duct, relocation

490

225

1130

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

302

154

1133

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

551

276

1134

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

416

184

1135

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

624

282

1140

Salivary calculus, removal of

99

92

1150

Submandibular salivary gland, excision of

229

92

1151

Excision of sublingual gland

148

92

THYROID GLAND:

1152

Thyroid cyst(s) aspiration/fine needle biopsy

40

0

1154

Excision of thyroid cyst

345

184

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

1156

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

68

72

1155

Total/revision thyroidectomy

500

205

1157

Partial/subtotal thyroidectomy

471

205

TONGUE:

1165

Excision of epithelioma of tongue with radical operation on glands

490

225

1170

Frenectomy (tongue tie)

49

72

1175

Hemiglossectomy

312

154

1176

Total glossectomy

624

236

1180

Growths of tongue, diathermy to

49

72

1185

Excision biopsy, oral cavity

74

72

1186

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

936

461

BREAST:

1190

Abscess, incision and drainage of

74

72

1191

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

40

0

1195

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

68

92

1200

Cysts or benign tumours, excision of, or segmental resection

142

92

1205

Duct papilloma, excision

148

92

1210

Gynaecomastia (excision for), unilateral

184

102

1211

Gynaecomastia (excision for), bilateral

343

154

1214

Segmental mastectomy with axillary sampling

294

154

1215

Total mastectomy

294

154

1216

Mastectomy with axillary clearance

468

154

1217

Quadrant mastectomy with axillary clearance

468

154

1218

Mammographic wire guided breast biopsy

160

72

LYMPHATICS:

1310

Axillary/inguinal lymph node(s) superficial dissection of

100

92

1315

Axillary lymph nodes complete dissection of

343

123

1320

Axillary or inguinal lymph nodes, incision of abscess

100

72

1326

Deep cervical node excision biopsy (not needle biopsy)

100

72

1335

Inguinal or pelvic lymph node block dissection, unilateral

368

164

1336

Inguinal or pelvic lymph node block dissection, bilateral

550

256

1355

Lymphatic infusion

245

0

1365

Primary or secondary retroperitoneal, lymphadenectomy complete, transabdominal

589

307

MUSCLES:

1370

Haemangioma of muscle, excision and repair of

294

123

1375

Muscle, manipulation and stretching of

49

0

1380

Muscle, repair and suture of

196

92

1385

Muscle biopsy

68

72

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

1390

Nerve biopsy

134

72

1395

Nerve repairs (primary)

392

133

1400

Nerve suture (secondary, including grafting and anastomosis)

441

184

1405

Neurectomy or local excision of neuroma

294

92

TENDONS: (See also Orthopaedic and Plastic Sections)

1410

Tendon repairs (primary) single

196

123

1415

Tendon repairs (primary) multiple

392

184

1420

Tendon sheath, incision of

99

77

1425

Tenotomy

99

72

1426

Tenolysis

196

92

VASCULAR:

1427

Supra-renal aneurysm repair

834

410

1428

Repair of super renal aortic aneurysm rupture

1076

410

1429

Tube graft repair of abdominal aorta

754

410

1431

Repair of ruptured abdominal aortic aneurysm

1034

410

1432

Aorto bi-iliac bypass for atherosclerosis or aneurysm

334

410

1433

Aorto-femoral or bifemoral bypass for atherosclerosis or aneurysm

834

410

1434

Endarterectomy of abdominal aorta and iliac vessels

754

410

1436

Repair of ruptured iliac artery aneurysm

754

410

1437

Endarterectomy of iliac vessels alone

646

410

1438

Visceral artery repair, re-anastomosis or endarterectomy

834

410

1439

Renal artery anastomosis, endarterectomy or re-implantation or bypass

834

410

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

1441

Embolectomy of visceral branches, superior mesenteric or renal arteries

592

184

1442

Removal of infected aortic prosthesis

1076

512

1443

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

834

256

1444

Repair of abdominal aortic trauma

592

256

1446

Aortic exclusion by axillo-femoral bypass

700

256

1447

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

1076

410

1448

Patch repair of internal carotid artery

323

184

1449

Vertebral artery bypass or repair

700

256

1451

Open repair of subclavian artery

592

256

1454

Translocation of common carotid to subclavian artery

700

256

1456

Carotid subclavian bypass

700

358

1457

Subclavian/subclavian bypass

592

256

1458

Thoracotomy with repair of vessels of arch of aorta

834

410

1285

Intra arterial injection (excluding arteriography)

74

0

1305

Renal stenosis, repair of

490

256

1306

Transcatheter embolisation

294

184

1307

Transcatheter removal of intravascular thrombus or foreign body

294

184

5866

Percutaneous angioplasty

294

205

VASCULAR - HEAD, NECK and UPPER LIMBS:

1459

Subclavian to branchial bypass or endarterectomy

592

358

1461

Repair of subclavian aneurysm

539

358

1462

Brachial embolectomy

323

184

1463

Repair or bypass of brachial to radial or ulnar vessel

700

256

1464

Repair of trauma to brachial artery with endarterectomy patch or bypass

592

256

820

Arterial venous fistula in arm under L.A.

196

164

821

Gortex graft placement for AV access for dialysis

441

164

1290

Ligation of major vessels

245

154

1250

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

89

77

VASCULAR - LOWER LIMBS:

1467

Femoral popliteal bypass, above knee vein

646

256

1468

Femoral to popliteal bypass, above knee synthetic

592

256

1469

Femoral to popliteal bypass, below knee vein

754

256

1471

Femoral to popliteal bypass, below knee synthetic

646

256

1472

Profundaplasty with or without patch or endarterectomy

485

256

1473

Common femoral artery endarterectomy

376

184

1474

Repair of femoral artery aneurysm

539

256

1280

Common femoral artery embolectomy

295

184

1476

Popliteal artery embolectomy

485

256

1477

Tibial artery embolectomy

592

256

1478

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

915

410

1479

Popliteal aneurysm artery repair or bypass

592

256

1481

Femoral/femoral bypass

646

256

1482

Repair of femoral or popliteal vessels due to trauma

700

256

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

392

154

1484

As 1483 for one leg

269

123

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)

294

154

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)

196

123

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)

294

154

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)

196

123

1491

Cockett, Linton or Dodd procedure on perforators

392

154

1492

Ligation and division at the sapheno-femoral junction of the long saphenous vein with ligation and avulsion of multiple varicose veins, one or both legs

196

123

1430

Iliac or femoral veins, removal of thrombus from

245

123

1435

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

392

184

1440

Ligation and division of individual perforator

74

77

1450

Portosystemic shunt

646

358

1455

Sclerosing operation on vein(s), one leg

49

0

1460

Sclerosing operation on veins, both legs

74

0

1465

Splenorenal anastomosis

490

307

1490

Varicose veins, exploration and removal of thrombus, unilateral

245

123

1495

Varicose veins, exploration and removal of thrombus, bilateral

294

154

1500

Venous pressure and blood volume studies

45

0

SKIN and SUBCUTANEOUS TISSUES:

1505

Abscess, cyst or tumour, aspiration of

49

72

1506

Angioma cauterisation or injection into, under general anaesthetic

49

72

1507

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

74

72

1508

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

148

82

1509

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

64

0

1510

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

74

72

1513

Ellipse biopsy of the skin

86

0

1514

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

74

72

1525

Foreign body, removal of

74

72

1540

Skin abscess, (superficial) incision and drainage of

74

72

1545

Keloid or other scar, excision of

74

72

1546

Enucleation of lipoma

99

87

1550

Malignant melanoma, wide excisional biopsy

148

87

1551

Malignant melanoma, wide excisional biopsy and graft

268

113

(See "LYMPHATICS" for block dissection of glands)

1555

Excision of pigmented naevi

74

72

1560

Incision and drainage of pilonidal abscess

71

72

1561

Pilonidal sinus or cyst, excision of

200

123

1565

Tubed pedicle flap, per stage

294

154

1570

Removal of foreign body from hand or foot under anaesthetic

74

77

1575

Basal cell carcinoma / squamous cell carcinoma, simple excision

148

72

1576

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

294

97

1577

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

172

77

1580

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

99

72

1586

Laser treatment to naevi, initial patch test

74

72

1587

Laser treatment to naevi, each subsequent treatment session

148

72

1588

Excision of axillary skin for hyperhidrosis

196

92

1591

Hydradenitis suppurativa, excision and suture

122

72

1592

Hydradenitis suppurativa, excision and graft

294

113

1605

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

99

72

1610

Interstitial implant with radioactive source

99

72

1615

Wounds and sinuses, curettage of

74

72

1620

Wounds (multiple), suture or excision and suture

148

87

1625

Simple repair of superficial wounds

72

72

OTHER PROCEDURES

1630

Exchange transfusion

134

0

1635

Exchange transfusion (intra uterine)

196

0

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

1631

Hyperbaric oxygen therapy, initial, including full medical evaluation

148

0

1632

Hyperbaric oxygen therapy, subsequent, per session

49

0

1636

Intravenous immunoglobulin for patients with a haematological malignancy or immune deficiencies

48

0

1637

Blood transfusion for patients with a haematological malignancy or immune deficiencies

48

0

1638

Intravenous antibiotics for patients on cytotoxic chemotherapy regimens for malignant disease

48

0

1639

Electrolyte replacement for patients on cytotoxic chemotherapy regimens for malignant disease

48

0

1641

Therapeutic phlebotomy for patients with polycythemia rubra vera or haemochromatosis

49

0

1642

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

490

225

1645

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

294

143

1646

Plasmapheresis.

49

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 inpatient.

72

0

1658

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

48

0

1663

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

99

72

4281

Bone marrow aspiration

45

72

4282

Bone marrow biopsy

68

72

4287

Bone marrow aspiration and biopsy

89

72

4283

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

834

0

4284

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

686

0

4286

Bone marrow harvesting

148

123

4288

Peripheral blood stem cell harvesting

148

0

4291

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

686

0

EAR, NOSE AND THROAT

EAR: (See also Plastic Section)

1665

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

364

154

1666

Attico antrostomy, unilateral

490

205

1670

Ear polyp, excision of

74

72

1671

Ear toilet requiring use of operating microscope and micro inspection of tympanic membrane with or without general anaesthesia, unilateral or bilateral

74

72

1675

Drainage external ear, abscess or haematoma

74

72

1680

External auditory canal excision of tumour

148

72

1685

External auditory canal removal of exostosis or osteoma

156

72

1686

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

291

143

1690

Facial nerve decompression (in temporal bone)

490

184

1695

Facial nerve graft (in temporal bone)

540

205

1700

Removal of foreign body from ear, under general anaesthetic

99

72

1701

Labyrinthectomy; transcanal

364

184

1710

Mastoidectomy, radical with or without labyrinthectomy

520

239

1715

Mastoidectomy, simple

416

205

1730

Myringoplasty

343

184

1735

Myringotomy

62

72

1740

Myringotomy (bilateral)

104

82

1741

Removal of drain tube(s) under general anaesthetic

49

72

1751

Pinna, total excision

196

102

1752

Pinna, partial excision with flap reconstruction

294

143

1753

Pinna, partial excision and graft

196

123

1755

Preauricular sinus, excision of

196

102

1760

Saccus endolymphaticus for Meniere's Disease

441

225

1765

Sebaceous cyst of ear, removal of

99

72

1770

Stapedectomy

589

225

1771

Stapedectomy with plastic reconstruction of ossicles

589

225

1790

Tympanoplasty

540

225

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

5980

Combined approach tympanoplasty

639

256

1785

Myringotomy with insertion of grommet

146

72

1786

Myringotomy, bilateral, with insertion of grommets

202

82

1796

Electrocochleography

27

72

NOSE:

1800

Epistaxis anterior packing and/or cautery

99

72

1805

Epistaxis posterior anterior packing and/or cautery

134

82

1810

Epistaxis anterior ethmoid and/or internal maxillary ligation

196

102

1815

Foreign body, removal under general anaesthetic

66

72

1820

Polypectomy, single

55

72

1825

Polypectomy, multiple

148

77

NOSE and ACCESSORY SINUSES: (See also Plastic Section)

1830

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

245

113

1840

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

368

164

1850

Antral biopsy

45

77

1855

Antral puncture (antrotomy) and washout unilateral

99

72

1860

Antral puncture (antrotomy) and washout bilateral

148

72

1865

Antral lavage involving insertion of polythene tube (unilateral)

148

72

1870

Antral lavage involving insertion of polythene tubes (bilateral)

196

72

1875

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

166

82

1880

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

122

72

1885

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

196

87

1890

Repair of choanal atresia, intranasal

218

102

1895

Repair of choanal atresia, transpalatine

441

205

1896

Crawford tube insertion, unilateral

99

77

1897

Crawford tube insertion, bilateral

148

82

1900

Ethmoid area malignant tumour excision

416

205

1905

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

94

77

1910

Ethmoidectomy extranasal (unilateral)

196

92

1915

Ethmoidectomy extranasal (bilateral)

364

164

1920

Ethmoidectomy intranasal (unilateral)

239

113

1925

Ethmoidectomy intranasal (bilateral)

231

138

1935

External frontal sinus exploration

490

205

1940

External frontal sinus operation for malignant disease

589

256

1945

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

490

225

1968

Nasal septum insertion of prosthetic button

122

77

1969

Plastic repair of nasal septum

364

164

1970

Nasal septum, submucous resection of

196

72

1980

Naso pharyngeal tumour, excision of

624

307

1985

Oro antral fistula, closure of

490

205

1990

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

99

72

1992

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

281

133

1993

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

312

154

1745

Nostril closure for atrophic rhinitis

196

77

4525

Rhinoplasty

441

184

5975

Rhinoplasty, primary, including major septal repair

528

221

THROAT:

1995

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

99

154

1996

Bronchoscopy with bronchoalveolar lavage (includes irrigation of bronchial tree)

115

0

1997

Bronchoscopy with transbronchial biopsy of lung

179

41

2003

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

201

41

1999

Bronchoscopy with laser ablation/resection of tumour

294

123

2000

Bronchoscopy with brachytherapy or placement of radium source

294

92

2001

Bronchoscopy with selective bronchography

134

41

2002

Bronchial provocation testing (histamine, methacholine etc.)

179

0

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

2011

Bronchoscopy with or without bronchial biopsy

115

41

2012

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

125

125

2020

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

140

123

2030

Laryngoscopy

68

82

2040

Laryngectomy, all forms including vertical hemi laryngectomy and tracheostomy

759

358

2045

Larynx, microsurgery of

294

123

2050

Laryngofissure, external operation on

490

205

2055

Lateral pharyngotomy

426

201

2056

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

294

92

2057

Vocal cord augmentation (injection of teflon)

220

102

2060

Oesophagoscopy

68

82

2065

Oesophagoscopy with biopsy and dilatation

112

82

2070

Oesophagoscopy with removal of foreign body

140

92

2074

Upper G.I. endoscopy with oesophageal dilatation and lasertherapy

245

82

2075

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

74

82

2077

Oesophageal dilation and insertion of endoprosthesis

245

205

2079

Oesophagoscopy with multiple injection of oesophageal varices

148

123

5840

Oesophageal motility study

68

92

2080

Papilloma or cyst of larynx, excision of

196

123

2081

Balloon, dilatation of the oesophagus (includes endoscopy)

152

82

2085

Pharyngeal pouch or diverticulum, excision of

540

225

2090

Pharyngeal pouch or diverticulum endoscopic diathermy division

343

184

2096

Drainage and marsupialisation of cyst

220

102

2100

Pharyngolaryngectomy

832

404

2115

Incision and drainage, abscess; retropharyngeal or parapharyngeal

83

154

2125

Tonsils and/or adenoids (adults), removal of

230

102

2130

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

200

92

2131

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

122

154

2132

Tracheoesophageal puncture and insertion of prosthesis

172

123

2136

Transtracheal aspiration

89

0

OTHER PROCEDURES:

2126

Overnight oximetry

45

0

2133

Kveim test including follow up punch biopsy of skin

64

0

2134

Kveim test including follow-up ellipse biopsy of skin

86

0

2137

Mantoux test, injection and follow up interpretation

64

0

5895

Full pulmonary function studies carried out in a pulmonary function laboratory including report

86

0

2141

Prolonged post-exposure evaluation of bronchospasm after exercise, with multiple spirometric determinations as in 5895 including measurement of thoracic gas volume and expired gas determinations

99

0

2139

Full sleep study (polysomnography)

173

0

GYNAECOLOGICAL OPERATIONS

CERVIX:

2140

Cervix, amputation of

99

72

2145

Cervix, biopsy of

45

72

2146

Cervix, cone biopsy of

125

72

2150

Cervical polypi, removal of

49

72

2155

Cervix, dilatation of

49

72

2160

Cervix, local excision of lesion of

49

72

2170

Cervix, suture of

74

72

2171

Cervical cerclage

99

72

2175

Cervix, cautery of

49

72

2180

Cervix, examination under anaesthesia

45

72

2181

Colposcopy

62

72

2182

Colposcopy and biopsy including Lletz procedure and/or laser therapy

104

72

OBSTETRICAL:

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

2185

Caesarean hysterectomy

589

256

2190

Caesarean section (grant in aid for obstetrician's fees)

215

154

2200

Ectopic pregnancy, surgical management (laparoscopic or open): salpingectomy and/or salpingo oophorectomy (unilateral or bilateral)

245

205

2205

Hydatidiform mole (hysterotomy)

196

154

2206

Vaginal delivery (grant in aid)

144

0

2207

Epidural anaesthesia for vaginal delivery

0

138

UTERUS and ADNEXA:

2215

Aldridge sling operation

364

123

2220

Broad ligament, excision of cyst of

196

113

2225

Dilatation and curettage (diagnostic or therapeutic)

135

72

2235

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

399

143

2240

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

598

205

2241

Surgical repair of extensive tubal and peritubal disease consequent on pelvic inflammatory disease or endometriosis, unilateral or bilateral

312

143

2248

Hysteroscopy

74

72

2249

Transcervical endometrial resection

490

123

2250

Total abdominal hysterectomy

489

179

2255

Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)

728

205

2256

Total vaginal hysterectomy combined with anterior and posterior pelvic floor repair

645

179

2257

Total abdominal hysterectomy with unilateral or bilateral salpingo oophorectomy

530

179

2258

Resection of ovarian malignancy with total abdominal hysterectomy, complete procedure

728

256

2259

Debulking of ovarian carcinoma with or without omentectomy, complete procedure

520

205

2260

Sub total abdominal hysterectomy

392

179

2264

Total vaginal hysterectomy with urethropexy or urethroplasty

489

184

2265

Total vaginal hysterectomy

489

179

2267

Total vaginal hysterectomy and anterior or posterior pelvic floor repair

593

179

2270

Induction of radiation menopause

99

72

2273

Marlex sling procedure

196

123

2280

Myomectomy (multiple)

392

154

2285

Myomectomy (simple, single)

343

154

2289

Oophorectomy, unilateral or bilateral (complete or partial)

218

128

2300

Ovarian cystectomy, unilateral or bilateral

245

128

2319

Salpingectomy complete or partial, unilateral or bilateral

218

128

2354

Salpingostomy or salpingolysis, unilateral or bilateral

312

128

2364

Microsurgical tuboplasty (salpingostomy or salpingolysis), unilateral or bilateral

354

154

2365

Salpingo oophorectomy, complete or partial, unilateral or bilateral

245

133

2366

Salpingography and cannulisation for unblocking fallopian tubes, unilateral or bilateral

245

0

2370

Uterus, plastic reconstruction of

392

184

2375

Ventrosuspension/Gilliam's operation

196

123

VULVOVAGINAL:

2380

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

148

92

2385

Bartholin's gland cyst, excision of

125

72

2390

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

74

67

2391

Burch colposuspension

364

154

2395

Caruncle, vulvovaginal, removal of

74

72

2400

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

392

164

2410

Colpotomy

148

77

2415

Cystocele. repair of

196

128

2420

Cystocele and rectocele, repair of (including colpoperineorraphy)

245

164

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

2425

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

99

77

2430

Hymenotomy

74

72

2435

Hymenectomy

74

72

2440

Perineal tear complete repair of

294

128

2441

Partial vaginectomy

490

184

2445

Rectocele, repair of

245

128

2450

Stress incontinence, Marshall Marchetti, urethropexy for

364

164

2460

Vaginal fistulae (recto vaginal), repair of

245

154

2465

Vaginal fistulae (vesico vaginal), repair of

392

154

2470

Vaginal wall, suture of

148

77

2475

Vagina, plastic repair for dyspareunia

196

154

2480

Vulvectomy simple, without glands

392

154

2485

Vulvectomy radical, with glands

540

256

2486

Intracaviatory insertion of radioactive source, cervix, vagina or uterus

294

154

2484

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

148

113

2488

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

200

113

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.

172

113

2489

As 2467 but including dilatation and curettage (diagnostic/therapeutic)

234

113

OPHTHALMIC OPERATIONS

CONJUNCTIVA:

2490

Conjunctival flap

99

72

2493

Conjunctivectomy

74

72

2495

Conjunctival graft

148

77

2498

Conjunctival tumour with or without graft

197

77

2496

Cryotherapy, unilateral

196

72

2497

Cryotherapy, bilateral

295

82

2500

Cyst/Granuloma- excision of

74

72

2505

Foreign body- removal of, from conjunctiva

74

77

2520

Wounds, repair

99

77

2521

Symblepharon division

99

77

2526

Symblephora - division of (includes conjunctival graft)

197

92

2527

Conjunctival biopsy

74

72

ANTERIOR SEGMENT:

2522

Removal of foreign body from anterior chamber, magnetic

392

184

2523

Removal of foreign body from anterior chamber, non-magnetic

392

184

2524

Removal of implanted material from anterior chamber

392

184

2525

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

148

82

2580

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

245

72

2585

Paracentesis/Saemisch section etc.

245

123

2586

Reform anterior chamber secondary to trabeculectomy or post cataract surgery

245

123

CORNEA and SCLERA:

2530

Corneal grafting- penetrating/lamellar

589

138

2531

Removal of sutures (late Stage) corneal/sclera

74

72

2532

Keratoprosthesis

603

184

2533

Epikeratophakia

603

184

2535

Corneal surface removed and EDTA application

99

77

2510

Pterygium removal

99

77

2511

Pterygium removal and conjunctival graft

197

92

2540

Corneal tattooing

99

77

2548

Ulcer/Recurrent, erosion, surgical treatment/Cautery with or without pricking, with or without debridement, with or without cryotherapy - one or more treatments, per episode of illness

99

77

2546

Corneal scraping

99

77

2547

Corneal biopsy

99

72

2555

Corneal or scleral tumour, excision

245

123

2556

Perforating injury cornea and/or sclera not involving uveal tissue

246

123

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

2565

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

420

184

2566

Repair of scleral staphyloma with or without graft

589

184

2575

Foreign body, removal of, from cornea

74

72

2577

Keratotomy (Wedge resections, relaxing incisions etc; for the correction of abnormal refractive errors resulting from cataracts, corneal scars or post traumatic corneal astigmatism)

491

123

2579

Excimer laser therapy for corneal pathology, per course

323

133

EYELIDS:

2589

Biopsy of eyelids

67

72

2590

Chalazion - incision and curettage, one or more

99

72

2591

Botulinum injection for blepharospasm or to induce ptosis

122

72

2595

Ectropion

196

82

2600

Entropion

172

82

2596

Blepharophimosis - for pathology (not cosmetic)

258

123

2605

Epilation trichiasis

54

72

2606

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

108

72

2610

Injury to eyelid - repair (superficial)

74

72

2611

Opening of tarsorrhaphy

74

72

2615

Injury to eyelid - repair (deep)

196

92

2620

Lid papilloma

196

72

2625

Superficial dermoid or cyst - excision of

148

72

2626

Canthotomy

43

0

2630

Tarsorrhaphy

148

72

GLOBE:

2635

Evisceration of eye

295

123

2640

Excision of eye plus implant

343

154

2645

Removal of intraocular foreign body

392

184

2660

Removal of eye

295

143

IRIS, CILIARY BODY and CHOROID OPERATIONS:

2680

Division of anterior synechiae

245

102

2685

Cyclodialysis

343

154

2696

Cyclocryotherapy/Diathermy

343

154

2700

Goniotomy

392

154

2710

Iridectomy

245

123

2711

Pupil reconstruction post trauma, post surgery

392

184

2725

Iris tumour, removal

392

184

2726

Iris biopsy

245

123

2740

Trabeculectomy/Drainage procedure

539

128

2741

Laser trabeculoplasty, one or more treatments

313

143

2845

Local resection of ciliary body or choroidal tumour

603

154

2742

Trabeculectomy and tubes, etc.

581

143

LACRIMAL APPARATUS:

2750

Canaliculus repair with or without tube

343

184

2755

Dacryocystorhinostomy with or without tubes

392

184

2756

Removal of D.C.R. tube

43

0

2760

Lacrimal abscess (dacryocystitis) incision

74

72

2761

Lacrimal sac, syringing and probing

99

72

2764

Intubation of nasolacrimal duct

392

154

2766

Punctal closure with cautery or controller

74

72

2768

3 Snip operation of lacrimal punctum

99

72

2769

Correction of everted punctum : cautery only

74

72

2770

Lacrimal sac excision (dacryocystectomy)

392

154

2771

Lacrimal gland tumour excision

431

184

2772

Conjunctivo - dacryocystorhinostomy with Lester Jones tube

409

184

2775

Lacrimal sac, syringing

74

72

LENS:

2779

Repositioning of intraocular lens

295

128

2780

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

295

128

2785

Capsulotomy, needling (surgical)

148

92

2786

Revision of cataract wound

161

92

2795

Lens extraction

515

164

2802

Cataract extraction plus insertion of artificial lens (includes phacoemulsfication, etc.)

581

164

2803

For cataract extraction operations, all forms, where only monitored anaesthesia care is given, the anaesthetic benefit payable is shown opposite

0

82

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

295

123

2647

YAG laser - for capsulotomy, pupil formation, iridectomy, membranectomy, ciliary body treatment, glaucoma, one or more treatments

295

0

2806

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

431

123

MUSCLES:

2870

Routine squint operation, horizontal, vertical or oblique

392

123

2871

Transposition surgery - Jansens, Hummelsheim, Knapp procedure

539

184

2872

Adjustment post strabismus operation

129

72

2873

Botulinum toxin injection to extraocular muscles

122

72

2874

Muscle biopsy

108

72

ORBIT:

2890

Orbit, exenteration of

589

184

2895

Orbit, exploration of, including biopsy

295

143

2900

Orbit, removal of foreign body from

343

154

2905

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

441

205

2910

Orbit, repair of fracture of

392

205

2911

Orbitotomy

603

184

2915

Orbit, repair of fracture of, with plastic implant

491

205

2912

Trans nasal wiring

485

205

2920

Radio Active Source application

196

102

POSTERIOR SEGMENT:

2665

Prophylactic therapy for retinal detachment

409

184

2506

Removal of silicone oil

603

184

2675

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

735

256

2676

Vitrectomy

735

256

MISCELLANEOUS:

2875

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

74

72

2880

Examination of eye under general anaesthetic

97

72

2926

Fluorescein angiography

45

0

DENTAL / ORAL SURGERY

2940

Dental cysts of maxilla or mandible

148

92

2950

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

122

92

2980

Labial frenectomy with dissection of tissue

49

72

2985

Odontoma, excision of

122

82

3005

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

99

82

3010

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

148

97

3015

Reimplantation of tooth in socket with splinting

99

82

3020

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

99

82

3025

Small tumours of dental origin, removal of, includes biopsy

74

77

3030

Tuberosities, reduction of

99

77

ORTHOPAEDIC OPERATIONS

HAND: (See also Plastic Section)

3035

Abscess or infected tendon sheath of palmar spaces, drainage of

104

72

3039

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

343

154

3040

Arthrodesis of joint

208

92

3045

Arthroplasty using joint prosthesis single

208

92

3050

Arthroplasty using joint prosthesis two joints

309

113

3055

Arthroplasty using joint prosthesis more than two joints

441

143

3060

Bone tumours (benign), excision of

343

154

3070

Bursectomy

104

77

3075

Chondroma, excision of (multiple) with bone graft

343

154

3080

Chondroma, excision (single) with bone graft

245

123

3085

Exostosis, excision of

156

82

3095

Fracture of phalanges and/or metacarpals closed reduction

99

67

3100

Fracture of phalanx single internal fixation

156

82

3105

Fracture of phalanges multiple internal fixation

260

123

3110

Ganglion of hand, surgical removal

148

72

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

3115

Manipulation for treatment of dislocation of metacarpophalangeal joint

78

72

3120

Nail, removal of

49

72

3125

Nails, removal of all

99

72

3130

Application of plaster of Paris casts

49

72

3135

Synovioma, excision of

148

72

3136

Tendon repair - flexor-double (hand)

338

154

3140

Traumatic amputation of finger - single - reconstructive operation

208

102

3145

Amputation of two or more fingers

392

184

3150

Trigger finger, correction of

99

77

3155

Whitlow incision and drainage

49

0

WRIST:

3159

Arthroscopy of the wrist

179

123

3160

Arthrodesis, using bone graft

441

184

3165

Arthroplasty

490

184

3170

Aspiration, wrist joint

49

72

3175

Bone grafting operation on scaphoid

343

123

3176

Herbert screw fixation, scaphoid

260

123

3180

Carpal bone (lunate scaphoid trapezium), excision of

196

92

3181

Trapezial joint replacement

589

225

3185

Carpal tunnel, decompression

148

92

3190

Carpus or peri carpal dislocations, manipulation

156

77

3195

Corrective osteotomy of lower end of radius

294

123

3200

Dislocation open reduction of

294

143

3205

Fracture (Colles') internal fixation of

229

123

3210

Fracture (Colles') manipulation and plaster of Paris

135

87

3211

Fracture of distal radius, external fixation of

148

72

3215

Injection, wrist joint

49

0

3220

Ganglion, removal of aspiration

49

72

3225

Ganglion, removal of surgical

148

72

3229

Intercarpal fusion

260

123

3230

Nerve block for pain control

49

0

3235

Nerve median and ulnar nerve repair of

520

205

3240

Nerve median or ulnar nerve repair of

392

184

3245

Radial styloid, excision of

156

82

3250

Sympathetic block

99

0

3255

Synovectomy of wrist joint

294

123

3260

Tendon repair at wrist single

208

102

3265

Tendons repair at wrist multiple

312

143

3270

Tendon transfer about the wrist, single

258

123

3271

Tendon transfer about the wrist, multiple

387

154

3275

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

172

87

3276

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

276

143

FOREARM and ELBOW:

3280

Amputation through forearm

392

184

3285

Annular ligament, repair of

294

143

3290

Anterior capsulotomy and excision myositis ossificans

294

143

3295

Arthrodesis

490

205

3296

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

208

123

3300

Arthroplasty

593

225

3305

Aspiration and injection forearm/elbow

49

72

3315

Drainage of joint

99

72

3316

External fixation, upper limb

148

87

3320

Fracture forearm (complete) closed reduction and plaster of Paris

164

87

3325

Fracture forearm (greenstick) closed reduction and plaster of Paris

135

87

3330

Fracture about elbow, closed manipulation of

166

87

3335

Fracture dislocation, open reduction

392

154

3340

Fracture of forearm bones, open reduction of

446

154

3341

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

572

225

3345

Fracture of lateral condyle, open reduction of

361

154

3350

Fracture of medial condyle, open reduction of

364

123

3355

Fracture (supracondylar), closed reduction of

229

77

3360

Fracture olecranon, screwing of

260

87

3365

Closed treatment of elbow dislocation

104

72

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

3370

Nerve ulnar transplant

312

123

3375

Olecranon bursa, removal of

148

82

3380

Radius excision of head of

208

92

3381

Silastic interposition of radial head

364

184

3385

Synovectomy of elbow joint

392

184

3390

Tendon transplants about the elbow

260

113

3395

Tendon sheaths, removal of in forearm

245

113

3400

Tennis elbow advancement of extensor muscles

196

102

HUMERUS and SHOULDER:

3401

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

294

154

3402

Arthroscopic suture capsulorrhaphy for anterior shoulder instability

589

225

3403

Arthroscopy, shoulder, diagnostic with or without synovial biopsy

192

123

3404

Acromioplasty

294

143

5875

Shoulder replacement prosthesis

589

225

3405

Acromio clavicular joint, excision of

208

102

3410

Acromio clavicular joint, open reduction of

294

143

3411

Arthroscopic subacromial decompression

312

143

3412

Arthroscopic excision outer end clavicle

260

143

3413

Arthroscopic excision outer end of clavicle/subacromial decompression

364

184

3415

Amputation through arm

392

184

3420

Arthrodesis, humerus/shoulder

589

225

3425

Aspiration of joint, humerus/shoulder

49

72

3430

Biopsy, synovial, humerus/shoulder

68

72

3435

Capsulotomy (acute capsulitis)

166

72

3440

Disarticulation, humerus/shoulder

589

282

3445

Dislocation, open reduction, humerus/shoulder

490

225

3450

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

125

72

3455

Dislocation recurrent operation for, humerus/shoulder

490

225

3464

Forequarter amputation

624

282

3465

Fractured clavicle, closed reduction

122

77

3470

Fractured clavicle, open reduction

294

123

3475

Fractured humerus, open reduction with internal fixation

392

184

3480

Fractured humerus, open reduction and bone graft

490

184

3485

Fractured humerus, closed reduction

156

77

3490

Injection of joint, humerus/shoulder

49

72

3495

Manipulation of humerus/shoulder under general anaesthetic

78

72

3500

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

441

184

3509

Saucerising humerus in chronic osteomyelitis

312

143

3510

Subacromial bursectomy

343

154

3515

Tendon transplant about shoulder

343

154

SPINAL REGION:

3520

Anterior drainage of paravertebral abscess with bone graft

832

256

3521

Anterior release and fusion for scoliosis/kyphosis

1040

461

3525

Antero lateral decompression

540

256

3526

Antero lateral decompression involving two or more levels

1040

307

3530

Coccyx, excision of

294

102

3540

Epidural injection

125

0

3541

Caudal injection

125

0

3545

Epidural infusion with cannula

148

0

3550

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

567

256

3555

Fractured spine, open reduction of

936

256

3559

Chemonucleolysis for intervertebral disc

239

102

3560

Intervertebral disc, removal

526

205

3561

Needle aspiration of intervertebral disc

196

102

3563

Excision of thoracic intervertebral disc

735

307

3565

Laminectomy and exploration

490

205

3566

Neuralarch biopsy

125

72

3571

Posterior spinal fusion with instrumentation for scoliosis

1040

451

3580

Spina bifida closure

546

236

3585

Spina bifida lumbar spinal osteotomy

1040

236

3586

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

1040

461

3587

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

1144

461

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

3588

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

832

461

3589

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

1040

461

3590

Spinal manipulation, under general anaesthetic

99

72

3592

External fixature of the spine

437

205

3593

Synthetic fusion (GRAF) one level

728

307

3594

Synthetic fusion (GRAF) two level

936

461

3598

Spinal fusion, multiple level, with internal fixation

1040

461

3595

Spinal fusion

639

256

3596

Spinal fusion, in scoliosis spine, anterior and posterior

639

461

3597

Spinal fusion involving two or more levels

1040

307

3600

Vertebral body biopsy

268

123

3601

Spinal fusion, one level with instrumentation

936

461

3602

Removal of instrumentation

312

184

3603

Spinal stenosis decompression, one level

468

236

3604

Spinal stenosis decompression, two levels

520

236

SACRO - ILIAC JOINT REGION:

3605

Arthrodesis, sacro iliac joint

540

225

3610

Aspiration, sacro iliac joint

49

72

3615

Biopsy of sacro iliac joint region

94

72

3620

Injection, sacro iliac joint region

52

72

3625

Pelvic osteotomy (bilateral) in ectopia vesica

624

225

HIP and FEMUR:

3630

Acetabuloplasty shelf operation

397

164

3631

Internal fixation of acetabular fractures

834

307

3635

Acute dislocation manipulation for

166

77

3636

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

125

77

3640

Acute dislocation or fracture dislocation open reduction, hip/femur

490

225

3645

Above knee amputation

592

205

3650

Arthrodesis, hip/femur

686

307

3660

Arthroplasty of hip using prosthesis

624

225

3661

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

832

328

3665

Arthrotomy for loose body

416

164

3670

Colonna's arthroplasty

589

256

3675

Corrective osteotomy with or without internal fixation

520

205

3680

Curetting of greater trochanter and bursectomy

196

102

3685

Decompression operations or hanging hip operations

312

133

3690

Hind quarter amputation

807

358

3695

Drainage of hip joint for acute infection

208

102

3700

Exostosis of femoral neck in slipped femoral epiphysis, excision of

490

205

3705

Femoral condyle, osteotomy of

416

184

3709

Fractured femur, hemiarthroplasty

589

225

3710

Fracture shaft of femur open reduction with internal fixation

520

184

3715

Fracture shaft of femur closed reduction with traction

312

102

3720

Fracture femur (supracondylar) open reduction of

520

184

3723

Fractured shaft of femur, closed intramedullary nailing

489

184

3724

Fractured shaft of femur closed intramedullary - interlocking nail

624

307

3725

Fracture of neck of femur intramedullary nail fixation of

468

184

3730

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

489

184

3731

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

490

184

3732

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

645

256

3733

Pelvic fracture, external fixation

208

102

3735

Hip deformity, soft tissue operations for correction of

312

143

3740

Injection or aspiration of the hip

49

72

3745

Manipulation of hip closed, requiring general anaesthetic

62

72

3750

Open reduction and/or rotation osteotomy

520

205

3751

Open reduction, pelvic osteotomy and femoral shortening

686

307

3755

Pelvic osteotomy

490

256

3756

Modified innominate osteotomy including bone graft

686

307

3760

Pseudoarthroplasty of hip (Girdlestone operation)

458

205

3765

Slipped femoral epiphysis intramedullary nail. fixation of

458

184

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

3770

Slipped femoral epiphysis lower end stapling of

294

154

3775

Synovectomy of hip joint and debridement

441

205

3785

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

441

205

KNEE and LOWER LEG:

3790

Below knee amputation

374

205

3795

Arthrodesis, knee

490

205

3810

Aspiration, knee/lower leg

49

72

3815

Baker's cyst excision of

294

113

3816

Bone transportation

437

205

3817

Removal of fixator device tibia

122

72

3819

Arthroscopy, knee, diagnostic, with or without synovial biopsy

166

123

3820

Cartilage(s), removal of, knee

294

143

3821

Arthroscopy and removal of cartilage, knee

343

154

3822

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

269

154

5890

Ligament reconstruction at the knee joint

490

225

5891

Ligament reconstruction of the knee joint using autogenous graft

490

225

3825

Corrective osteotomy of tibia in region of knee

441

184

3830

Corrective osteotomy of tibia in region of ankle

343

164

3835

Cruciate ligaments repair

392

184

3836

Arthroscopic anterior cruciate ligament reconstruction

490

225

3837

Arthroscopic anterior cruciate ligament reconstruction and menisectomy

603

225

3838

Arthroscopic anterior cruciate ligament reconstruction and menisceal repair

645

225

3839

Arthroscopic menisceal repair

385

154

3840

Drainage of joint in acute infection

171

72

3845

Exploration of joint, knee/lower leg

245

123

3850

Fixed flexion of knee soft tissue operations for

392

184

3855

Fracture dislocation of knee joint, operations for

540

225

3860

Fracture of tibia (condylar) open reduction of

490

205

3865

Fracture of tibial shaft open reduction and internal fixation

490

205

3870

Fracture of tibial shaft closed reduction

166

82

3875

Injection of joint, knee/lower leg

49

72

3880

Lateral ligaments, repair

343

154

3885

Manipulation under general anaesthetic, knee/lower leg

62

72

3890

Osteochondritis dissecans Smillies operation for

208

102

3895

Patellectomy or open reduction of fractured patella

343

154

3900

Pre patellar bursa, removal of

196

92

3905

Plication of vastii, etc.

208

92

3910

Prosthetic replacement (total) of knee joint

624

225

3911

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

728

307

3912

Reconstruction of knee, (anterior cruciate)

490

225

3915

Quadriceps mechanism repair

343

164

3920

Slipped epiphysis, stapling of, or epiphysiodesis

453

184

3925

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

490

225

3930

Slipped epiphyses (bilateral tibial), stapling of

416

184

3931

Slocum's or similar procedure

490

225

3935

Synovectomy

392

184

3940

Synovial biopsy, knee/lower leg

78

72

3945

Tendon transplants about knee joint

392

184

3950

Transplant of tibial tubercle

392

184

ANKLE:

3955

Arthrodesis of ankle joint

441

184

3956

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

232

123

3957

Arthroplasty (ankle)

291

143

3960

Aspiration and injection, ankle

49

72

3965

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

312

133

3970

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

343

143

3971

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

364

154

3975

Fracture Pott's closed reduction

196

102

3980

Synovectomy and debridement

343

154

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

3985

Synovial biopsy, ankle

68

72

3986

Talar fracture, open reduction and internal fixation of

343

143

3990

Tendo achillis, elongation of

294

154

3995

Tendo achillis, repair of

392

154

4000

Tendon transplants about the ankle joint and foot (multiple)

392

179

4005

Tendon transplants about the ankle joint and foot (single)

294

128

4010

Traumatic fracture and dislocation, open reduction of

392

133

4015

Unstable ankle Watson Jones operation for,

392

184

CONGENITAL TALIPES EQUINOVARUS:

4019

Astragalectomy

343

164

4020

Dwyer's Valgus osteotomy

312

143

4025

Manipulation and plaster fixation

74

82

4030

Manipulation and strapping

74

72

4035

Rotation osteotomy of tibia

406

184

4040

Soft tissue release

416

128

4045

Tarsal osteotomy

343

154

4050

Tendon transplant -single

294

143

4051

Tendon transplant -multiple

416

205

FOOT:

4060

Arthrodesis of all inter phalangeal joints (Lambrinudi) unilateral

294

143

4065

Arthrodesis of all inter phalangeal joints (Lambrinudi) bilateral

441

205

4070

Arthrodesis of first metatarso phalangeal joint

196

92

4075

Arthrodesis triple, in all its forms

490

205

4080

Arthrodesis, pantalar

589

225

4085

Claw foot (Steindlar) muscle stripping operations for

196

102

4090

Exostosis of first metatarsal (unilateral), removal of

171

77

4095

Exostosis of first metatarsal (bilateral), removal of

229

92

4100

Flat foot involving joint fusion, operation for

341

143

4101

Flexor tenotomy, single (foot)

104

77

4102

Flexor tenotomy, multiple (foot)

156

92

4103

Fracture of hindfoot, internal fixation, unilateral

312

143

4104

Fracture of hindfoot, internal fixation, bilateral

468

205

4105

Fracture of phalanges and/or metatarsals (closed reduction)

99

77

4110

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

148

92

4115

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

294

123

4120

Ganglion of foot, excision of

104

72

4125

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

294

123

4130

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

392

123

4135

Hammertoe unilateral, correction of

148

92

4140

Hammertoe bilateral, correction of

220

113

4145

Grice's operation, subtalar bone block

148

72

4150

Ingrowing toe nail hemiphalangectomy

148

72

4155

Avulsion of nail plate, partial or complete, simple

48

0

4160

Ingrowing toe nail, removal of nail and nail bed

134

72

4165

Injection and manipulation, foot

49

72

4170

Laprau's operation to correct position of toe

171

92

4175

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

232

113

4180

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

364

164

4181

Metatarsal joint replacement with prosthesis

490

205

4182

Metatarsal osteotomy, unilateral

208

113

4183

Metatarsal osteotomies, bilateral

312

164

4184

Chevron osteotomy-single

312

143

4185

Os calcis, osteotomy of (Dwyer)

312

143

4190

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

196

92

4195

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

294

143

4200

Plantar fascia, excision or division of (unilateral)

196

92

4205

Plantar fascia, excision or division of (bilateral)

294

143

4210

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

72

72

4211

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

16

0

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

4215

Stamm's operation, unilateral

392

164

4220

Stamm's operation, bilateral

441

205

4225

Talectomy

392

184

4230

Tarsal osteotomy

245

113

4235

Tendon transplantation about the foot, multiple

392

184

4240

Tendon transplantation about the foot, single

294

123

4245

Tendon transplantation flexor and extensor all toes, unilateral

441

184

4250

Tendon transplantation flexor and extensor all toes, bilateral .

540

225

4255

Trans metatarsal amputation of foot

295

113

4260

Trans metatarsal amputation of one toe

177

72

4261

Trans metatarsal amputation of two or more toes

295

113

MISCELLANEOUS:

4264

Arthroscopy

104

123

4265

Arthrotomy for removal of loose bodies

196

92

4270

Biopsy of tumour of long bones open

104

82

4271

Costotransversectomy

281

102

4272

Excision of large malignant bone tumours for limb conservation

884

256

4273

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

988

307

4275

Body plaster application

196

92

4270

Bone cysts excision

245

92

4285

Bursectomy large joints

196

92

4290

Chondroma removal

441

184

4295

Exostosis of long bones removal

208

92

4300

Fracture sternum and ribs operative reduction

245

205

4301

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

589

225

4305

Long bones, sequestrectomy, decortication or bone graft

441

184

4310

Osteomyelitis drilling of bones

232

92

4315

Osteomyelitis, marsupialisation and bone grafting

490

184

4320

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

122

92

4325

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

268

123

4330

Trimming of stump following amputation of limb

171

77

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)

196

123

4340

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

490

184

4350

Graft of extensive areas beyond 10%

589

225

4355

Graft of granulating areas less than 10%

245

123

4360

Major burns of face, excision and graft of

490

164

4365

Major burns of hands, excision and graft of

490

143

4370

Smaller areas, excision and graft of

294

92

BURNS - LATE DEFORMITIES:

4385

Inlay grafts (ankle)

392

184

4390

Inlay grafts (elbow)

245

123

4395

Inlay grafts (fingers)

245

123

4400

Inlay grafts (knee)

392

184

4405

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

196

92

4410

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

196

92

CLEFT LIP and PALATE:

4415

Adjustment of lip margin

99

72

4420

Adjustment of scars, secondary

99

72

4425

Cleft palate reconstruction

392

174

4430

Complete cleft tip and anterior palate repair

490

225

4431

Primary repair, unilateral cleft lip

490

174

4432

Primary repair, bilateral cleft lip

515

225

4433

Secondary repair, unilateral cleft lip

490

174

4434

Secondary repair, bilateral cleft lip

515

225

4440

Fistula, secondary closure of

392

174

4460

Maxillary bone graft

490

225

4465

Nostril margin, secondary correction of

294

123

4466

Total cleft rhinoplasty

441

205

4470

Pharyngoplasty (not for snoring)

392

184

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

4475

Soft palate partial cleft, reconstruction of

343

143

BREAST RECONSTRUCTION:

4479

Nipple reconstruction

269

128

4480

Breast reduction

686

225

4481

Breast augmentation (implants)

269

128

4482

Plastic repair of inverted nipple

294

154

4483

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

589

307

4484

Mastopexy including full thickness graft from other areas

490

225

4485

Breast reconstruction, vertical rectus flap, post mastectomy

565

307

4486

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

466

256

4487

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

466

256

4488

Breast reconstruction, implant only, post mastectomy

172

128

TISSUE EXPANDERS:

4551

Insertion of expander including any subsequent injections of expander

441

184

4552

Removal of expander

148

92

4553

Removal of expander and inserting of expanded skin

319

154

EYELIDS:

4490

Eyelid bags, repair of

343

123

FACIAL TRAUMA:

4489

Facial trauma, suturing of facial nerve

392

184

4491

Facial trauma, suturing of facial nerve branch

343

154

4492

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

490

225

FACIAL TUMOURS:

4493

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

565

256

DELAYED FACIAL REANIMATION - SKIN and DERMAL HITCHES:

4494

Wedge excision of lower lip

343

154

4496

Nasolabial skin/dermal hitch

245

113

STATIC SLINGS:

4497

Temporalis fascial sling, oral, nasolabial, ocular

639

307

4498

Orbicularis oris hitch

639

307

DYNAMIC SLINGS:

4499

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

639

307

NERVE TRANSFERS:

4500

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

589

282

4501

Cross facial nerve grafting, hypoglossal/facial nerve reanimation

834

358

COMPLEX FREE TISSUE TRANSFER:

4502

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

834

358

4510

Facial reanimation in facial paralysis (unilateral)

639

307

OTHER PROCEDURES:

4520

Moles or cysts, excision and suture (Plastic)

99

72

4530

Facial scars, dermabrasion, per scar

99

72

4535

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

343

102

4540

Scars on trunk excision or Z plasty

343

123

4545

Wounds of face suture (per wound)

99

72

EAR:

4555

Accessory auricles, removal

99

72

4560

Epithelioma of ear, excision and reconstruction, lobule placement

196

92

4561

Cartilage graft(s). reconstruction of ear

441

184

4562

Ear reconstruction, further minor procedures

196

92

4575

Protruding ears correction with reconstruction of folds (bilateral)

368

123

4530

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

245

92

EYES:

4585

Contracted socket

539

154

4590

Cyst of eyelids, excision of

99

72

4595

Enophthalmos bone graft

441

205

4605

Decompression, orbit

491

205

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

4610

Eyebrow graft

196

92

4615

Eyelids, repair of, for avulsion

196

92

4620

Eyelid, inlay grafts (one lid)

343

154

4625

Eyelid operations in facial paralysis

294

123

4630

Eyelid, total reconstruction of

490

225

4635

Muscle advancement for ptosis (unilateral)

368

164

4640

Naso lacrimal duct, reconstruction of

245

123

GENITO URINARY:

4645

Ectopia vesica (reconstruction of bladder)

490

256

4650

Ectopia vesica (reconstruction of urethra) (per stage)

245

123

4655

Epispadias, correction of dorsal curvature

294

133

4660

Epispadias, reconstruction of urethra

294

133

4665

Hypospadias, correction of ventral curvature or chordee

294

133

4670

Hypospadias, fistula closure

294

133

4675

Hypospadias, reconstruction of urethra

343

154

4676

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

760

358

4680

Urethra, plastic reconstruction of

392

143

4681

Insertion of Jonas penile prosthesis

294

154

4882

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

416

205

4685

Urethra, second stage, reconstruction of

490

205

4686

Cliteroplasty

416

205

4690

Vaginal reconstruction with skin graft

490

205

4691

Young Dee's Leadbetter operation

735

307

HANDS:

4695

Congenital hand deformities reconstruction on each hand (per stage)

343

164

4700

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

196

102

4705

Contractures extensive straightening of hand and inlay grafts

343

164

4710

Contractures, localised, division and graft

196

102

4711

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

392

184

4712

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

540

246

4715

Dupuytren's contracture fasciectomy (one or two fingers)

294

123

4720

Dupuytren's contracture fasciectomy (three or more fingers)

416

154

4721

Dupuytren's contracture, palm and fingers

416

154

4730

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

540

205

4735

Injury to hand, moderate, wound repair or graft

294

123

4740

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

540

256

4745

Neoplasm, major excision and repair with tendon grafts and flaps

589

256

4750

Neoplasm, localised excision and graft

294

143

4760

Nerve repair, primary, single or multiple

343

174

4765

Nerve repair in extensively scarred hand

490

225

4770

Opposition strut graft to thumb

392

205

4775

Palmar ganglion, compound, synovectomy of

392

184

4780

Policisation (finger replacement of lost thumb)

639

307

4785

Syndactyly, repair of (single)

392

154

4790

Syndactyly, repair of (multiple)

392

184

4795

Tendon grafting, single

343

164

4800

Tendon grafting, multiple

490

205

4805

Tendon repair, single

294

92

4810

Tendon repair, multiple

392

184

4815

Tendon transplants, for restoration of opposition

392

184

4820

Tendon transfers for paralysis, multiple

540

256

4825

Tube pedicle or flap reconstructions, first stage

441

205

4830

Tube pedicle or flap reconstructions, second stage

368

184

4835

Tube pedicle or flap reconstructions, final stage

490

225

4840

Wound suture of

99

72

MAXILLA and MANDIBLE:

4845

Facial bone, simple fixation of undisplaced fracture (e.g. jaw sling)

148

102

4850

Facial bones, tumours of, major resection and/or reconstruction

589

307

4855

Fracture of maxilla or mandible, open reduction and fixation

392

184

4860

Fracture of maxilla or mandible, fixation of undisplaced

245

154

4865

Fracture of maxilla or mandible, malar bone or part of these, reduction without fixation

245

123

4870

Hypertelorism correction, sub cranial

686

358

4875

Mandible, excision of

490

256

4880

Maxilla or mandible, advancement or recession osteotomy of

392

256

4881

Maxillary and mandibular osteotomy

589

307

4885

Orbital floor, fracture of, reduction, direct wiring and build up from antrum

490

256

4890

Orbital floor, secondary bone grafting

392

205

4895

Osteomyelitis or abscess of facial bones, operation for

245

123

4900

Temporo mandibular joint, reduction of dislocation under general anaesthetic

99

82

4901

Arthroscopy, temporo mandibular joint for release of adhesions or arthroplasty, with or without biopsy

196

184

4905

Temporo mandibular joint, condylectomy for ankylosis

343

307

NOSE:

4910

Bone graft

441

205

4915

Nasal tip deformities, correction of

343

154

4920

Fracture of nose, digital closed reduction

49

72

4925

Fracture of nose, instrumental closed reduction

74

82

4926

Fracture of nose, instrumental closed reduction with plaster of Paris fixation

99

82

4927

Fracture of nose, instrumental closed reduction with reduction of septum and plaster of Paris fixation

148

82

4930

Fracture of nose, open reduction

99

102

4935

Fracture of nose, open reduction with internal or external fixation

220

123

4940

Fracture of nose, open reduction with open reduction of fractured septum

343

184

4945

Reconstruction with imported flaps, partial

441

205

4950

Reconstruction with imported flaps, total

540

256

4955

Re fracture and open corrective rhinoplasty

490

205

SKIN REPLACEMENT AND RECONSTRUCTIONS

LOCAL GRAFTS and FLAPS:

4956

Excision of lesion and split skin graft

196

102

4957

Excision of lesion and full thickness (Wolfe) skin graft

196

102

4958

Excision of lesion, local flap face

294

102

4959

Excision of lesion, local flap hand

294

102

4961

Excision of lesion, local flap limb

245

102

4962

Excision of lesion, local flap trunk

245

102

CUTANEOUS FLAPS:

4963

Excision of lesion including scalp rotation flap

245

102

4964

Excision of lesion including cheek rotation flap

368

154

4966

Excision of lesion including ceivicofacial rotation flap

368

154

4967

Excision of lesion including forehead flap

392

184

4968

Excision of lesion including deltopectoral flap

466

205

4969

Excision of lesion including groin flap

466

205

FASCIOCUTANEOUS FLAPS:

4971

Fasciocutaneous flap upper limb

368

184

4972

Fasciocutaneous flap lower limb

368

184

4973

Fasciocutaneous flap trunk

368

184

(Flap repair is payable in addition to the primary operation for procedures 4974 to 4989

MYOCUTANEOUS FLAPS:

4974

Myocutaneous flap, pectoralis

343

164

4976

Myocutaneous flap, latissimus dorsi

343

164

4977

Myocutaneous flap, latissimus dorsi with serratus and rib

368

184

4978

Myocutaneous flap, vertical rectus

368

184

4979

Myocutaneous flap, transverse rectus (TRAM)

343

164

4981

Myocutaneous flap, tensor fascia lata

368

184

4982

Myocutaneous flap, gluteal

368

184

FREE MICROVASCULAR FLAPS:

4963

Free microvascular flap, radial forearm without bone

565

256

4964

Free microvascular flap, radial forearm with bone

614

256

4966

Free microvascular flap, latissimus dorsi

565

256

4987

Free microvascular flap, latissimus dorsi with serratus and rib

614

256

4988

Free microvascular flap, scapular

565

256

4989

Free microvascular flap, para scapular

565

256

(Flap repair is payable in addition to the primary operation for procedures 4953 and 4954)

4953

Free microvascular flap, fibula

565

256

4954

Free microvascular flap, deep circumflex iliac (DCIA)

565

282

REPLANTATION:

4991

Replantation, per digit

565

256

4992

Replantation, hand (mid palm)

834

358

4993

Replantation, hand (wrist)

712

328

4994

Replantation, forearm

785

358

4996

Replantation, foot

785

358

4997

Replantation, scalp

565

282

4998

Replantation, ear

565

282

TRAUMA:

4990

Major degloving injuries of limbs, excision and graft of

589

256

THORACIC OPERATIONS:

LUNGS:

5015

Lung abscess with thoracotomy, drainage of

540

307

5025

Pneumonolysis

343

225

5038

Refilling and maintenance of implantable pump or reservoir including access to pump port (see 5039)

74

0

5039

Implantation of catheter system and reservoir for administration of pain control therapy and/or chemotherapy

245

72

MEDIASTINUM:

5041

Myocardial biopsy

224

205

5055

Aortic endarterectomy

686

358

5065

Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter

110

0

5801

Exploration of mediastinum

313

307

5802

Endoscopic extirpation of lesion of mediastinum

313

307

5803

Diagnostic endoscopic examination of mediastinum

313

179

5804

Operation on lymphatic duct

500

307

5863

Thymectomy

540

358

5075

Blalock operation

589

410

5080

Cardiac catheterisation (left, right or both sides)

179

0

5090

Cardiac catheterisation and coronary angiography with or without ventriculography

301

0

5112

Cardiac catherisation and coronary angiography with or without ventriculography (including opacifaction of coronary bypass grafts)

320

0

5091

Cardioversion

122

61

5092

Venotomy and insertion of filter into the inferior vena cava

368

256

5093

Paediatric cardiac catheterisation (left, right or both sides)

268

205

5094

Paediatric cardiac catheterisation and cardiac angiography combined

404

225

5101

Coronary angioplasty, single or multiple vessel(s), with or without angiography with or without pacing

538

256

5098

Recatheterisation post angioplasty/angiography (within 6 months)

100

72

5855

Annuloplasty

589

307

5103

Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method one or more vessel(s)

600

358

5104

Intra coronary stent placement, post coronary angioplasty

540

307

5108

Cardiac ultrasound, (echocardiography) m-mode, 2D including ventricular function, chamber dimensions, wall motion, doppler exam (pulse, continuous wave, colour flow) assessment of valve areas, pressure gradients, regurgitant fractions

125

0

5109

Cardiac ultrasound, transoesophageal

60

0

5110

Heller's operation

392

256

5113

Pericardial drainage

112

154

5114

Continuous pericardial drainage

202

154

5118

Atherectomy

839

410

5120

Mediastinum (cysts, etc.) and contents, any operation on (excluding biopsy)

686

307

5135

Mediastinoscopy and biopsy

313

179

5136

Percutaneous transthoracic biopsy

89

102

5137

Percutaneous transthoracic biopsy under CAT guidance

215

205

5151

Percutaneous trans septal mitral valvuloplasty

839

410

5152

Valvuloplasty (other than mitral valvuloplasty)

588

307

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

5160

Oesophageal anastomosis

639

358

5870

Myocardial aneurysmyotomy

589

614

5161

Trachea oesophageal fistula repair of

639

512

5162

Repair, tracheo-oesophageal atresia

664

358

5163

Repair, tracheo-oesophageal fistula (TOF) atone (H-fistula)

581

358

5164

Repair, tracheo-oesophageal fistula (TOF) and atresia, replacement

834

410

5165

Oesophagectomy (all forms including three stage)

900

410

5170

Oesophagus, repair and short circuit

639

358

5171

Transection of oesophagus with repair, for oesophageal varices

491

358

5172

Oesophageal devascularisation

572

358

5180

Pott's operation

441

143

5190

Rashkind septostomy

392

256

5195

Resuscitation including electrical defibrillation and open cardiac massage

490

0

5200

Transeptal left heart catheterisation

196

100

5205

Vagotomy (through chest)

392

307

5217

Needle biopsy, transthoracic

89

102

5218

Needle biopsy, abdominal

89

72

5219

Trans thoracic electro - cautery of subclavian chain for arm

466

256

HEART:

5808

Transplantation of heart

2002

922

5809

Correction of tetralogy of fallot

1231

717

5811

Atrial inversion for transposition of great vessels

1231

717

5812

Other correction of transposition of great vessels

1308

717

5813

Correction of total anomalous pulmonary venous connection

1231

717

5814

Closure of defect of atrioventricular septum using dual prosthetic patches

1231

563

5816

Closure of defect of interatrial septum

1078

563

5817

Closure of defect of interventricular septum

1078

563

5818

Planned repair of post infarction ventricular septal defect

1078

717

5819

Emergency repair of post infarction ventricular septal defect

1308

819

5821

Other open operations on the septum of the heart

1231

563

5822

Creation of valved cardiac conduit

1231

563

5823

Creation of other cardiac conduit

1231

563

5824

Refashioning of atrium (Ebstein's)

1231

563

5826

Operations on wall of atrium

1231

563

5827

Excision of cardiac tumour

1231

563

5828

Staged correction of hypoplastic left heart syndrome per stage

769

614

5829

Replacement of mitral valve (includes valvuloplasty)

1078

563

5831

Plastic repair of mitral valve

1078

563

5832

Replacement of aortic valve (includes valvuloplasty)

1078

538

5833

Replacement of tricuspid valve (includes valvuloplasty)

1078

563

5834

Replacement of pulmonary valve includes valvuloplasty valvotomy

1078

563

5836

Open valvotomy

1078

538

5837

Closed valvotomy

769

358

5838

Other open operation(s) on heart valves

1078

563

5839

Double valves

1231

717

5841

Removal of obstruction from structure adjacent to valve of heart

1078

563

5842

Triple valves

1386

717

5643

Valve and grafts

1386

717

5844

Saphenous vein graft bypass for coronary artery(ies)

1231

538

5846

Autograft bypass for coronary artery(ies)

1231

538

5847

Allograft bypass for coronary artery(ies)

1231

533

5848

Prosthetic bypass for coronary artery(ies)

1231

538

5849

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

1231

538

5851

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

1231

538

5852

Correction of anomalous coronary arteries

1231

538

5853

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

1231

538

5854

Map guided surgery for ventricular arrhythmias

1231

614

5856

Exploration of heart

1154

512

5857

Left ventricular aneurysmectomy

1078

614

5858

Open operations on heart

1078

512

5859

Insertion management and removal of ventricular assist device

769

410

5861

Insertion, maintenance and removal of aortic conterpulsation balloon pump

309

256

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

5862

Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial (single or dual chamber)

240

154

5864

Insertion or replacement of pacemaker pulse generator

170

102

5064

Insertion, replacement or repositioning of permanent transvenous electrode(s), single or dual chamber (15 days or more after initial insertion)

160

102

5867

Removal of pacing system with bypass

769

410

5868

Removal of permanent pacing system

185

154

5069

Insertion of automatic implantable cardioverter/defibrillator

430

130

5872

Excision of pericardium

769

358

5873

Decompression of cardiac tamponade (re operation for bleeding)

385

358

5874

Pericardiocentesis

153

205

5876

Transthoracic drainage of pericardium

309

205

5877

Incision of pericardium

309

205

5878

Rewiring of sternum

385

205

GREAT VESSELS:

5879

Correction of truncus arteriosus

1308

614

5871

Open correction of patent ductus arteriosus

577

307

5882

Closed correction of patent ductus arteriosus

540

307

5883

Creation of shunt to pulmonary artery from aorta using interposition tube prosthesis

577

307

5886

Connection to pulmonary artery from aorta

577

307

5887

Creation of shunt to pulmonary artery from subclavian artery using interposition tube prosthesis

577

307

5888

Connection to pulmonary artery from subclavian artery

577

307

5889

Repair of pulmonary, artery/ PA De Banding

1078

614

5884

Pulmonary artery banding

577

307

5892

Pulmonary embolectomy

1154

614

5893

Open operations on pulmonary artery

577

307

5894

Extra anatomic bypass of aorta

925

410

5896

Replacement of ascending aorta

1008

512

5897

Replacement of arch of aorta

1008

614

5898

Replacement of aneurysmal segment of thoracic aorta

1008

512

5899

Planned replacement of ascending aorta

1308

512

5901

Planned replacement of arch of aorta

1386

614

5902

Replacement of aneurysm of aorta

1154

512

5903

Other bypass of segment of aorta

1008

512

5904

Revision operation of prosthetic aortic grafts

1008

512

5962

Plastic repair of aorta (coarctation/ interrupted aortic arch)

1008

563

CHEST WALL:

5963

Repair of diaphragmatic hernia using thoracic approach

463

307

5907

Repair of congenital diaphragmatic hernia (anaesthetist benefit includes all pre-operative and post-operative intensive care for the child. The consultant anaesthetist should report all intensive care services using the Special Reporting Process, see pa

463

0

5908

Thoracoplasty one stage

616

307

5909

Excision of chest wall tumour

616

307

5912

Correction of pectus deformity of chest wall

639

307

5913

Reconstruction of chest wall

616

307

5914

Exploratory thoracotomy

269

205

5916

Resection of rib and open drainage of pleural cavity

343

205

5917

Repair of rupture of diaphragm

577

307

5918

Plication of paralysed diaphragm

463

307

TRACHEA:

5919

Partial excision of trachea

1000

563

5920

Reconstruction of trachea

1078

563

5921

Tracheostomy permanent

245

123

5922

Insertion of mini tracheostomy

77

72

5923

Destruction of lesion of trachea by rigid endoscopy

115

154

5924

Dilatation of tracheal stricture by rigid endoscopy

115

154

5928

Therapeutic operations on bronchus or lung using rigid bronchoscopy

115

154

FIBREOPTIC ENDOSCOPIC PROCEDURES UNDER TOPICAL ANAESTHESIA:

5931

Destruction of lesion of trachea

115

154

5932

Dilatation of tracheal stricture

115

154

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

5936

Dilatation of bronchial stricture by fibreoptic bronchoscopy

115

123

BRONCHI/LUNGS/PLEURA:

5941

Total pneumonectomy

700

307

5942

Lobectomy of lung (including excision of segment)

688

307

5947

Removal of lung, with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy)

832

410

5948

Removal of lung, with circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy)

780

358

5943

Thoracoscopic lung resections

686

307

5944

Open excision of lesion of lung

688

307

5946

Decortication of pleura or lung

686

307

5949

Pleurectomy for pneumothorax, open

539

307

5951

Endoscopic examination of pleura

231

154

5952

Insertion of tube drain into pleural cavity

100

0

5953

Introduction of substance into pleural cavity with chest aspiration

100

0

5954

Introduction of substance into pleural cavity with chest drain

100

0

REVISION SURGERY:

5956

Revision coronary artery surgery

1354

538

5957

Revision repair of coarctation of aorta

1109

563

5958

Revision closure of defect of intra ventricular septum

1186

563

5959

Revision of valve surgery

1186

717

PLEURA:

5220

Apicolysis

343

205

5221

Closed pleural biopsy

89

0

5230

Empyema, drainage

343

256

5231

Percutaneous drainage of empyema

99

0

5234

Paracentesis thoracis

45

0

5235

Paracentesis thoracis with intercostal drain

134

0

5240

Paracentesis thoracis with infusion of cytotoxic drugs

148

0

5245

Phrenic avulsion

148

154

5250

Pleurodesis

245

154

5251

Closed drainage of pneumothorax

148

0

5260

Thoracoscopy

224

205

5265

Thoracoscopy with intrapleural procedure

343

256

5270

Thoracotomy including lung or pleural biopsy

313

256

5274

Exploration for post operative haemorrhage or thrombosis, chest

392

358

ULTRASOUND/VASCULAR STUDIES:

5926

Full mapping

1008

512

5930

Lower limb arterial ultrasound examination

68

0

5935

Venous ultrasound examination

68

0

5940

Duplex ultrasound scan

134

0

5960

Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement

347

110

5961

Intracardiac catheter ablation of arrhythmogenic focus for treatment of supraventricular of ventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combinatio

500

200

5502

Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, HIS bundle recording, including insertion and repositioning of multiple electrode catheters

240

0

NEUROSURGICAL OPERATIONS:

BRAIN and MENINGES:

5290

Aneurysms (direct operations)

1248

461

5292

Detachable balloon occlusion of carotico cavernous aneurysms and fistulae

973

358

5295

Anomalies (direct operations) including haemangioma

1040

461

5305

Biopsy of brain

520

307

5320

Brain tumour (all forms not otherwise listed)

832

358

5325

Brain wounds, open

832

307

5330

Calcified subdural haematoma, excision of

540

358

5345

Carotid ligation, neck

294

154

5350

Carotid ligation, removal

196

123

5360

Cisternal puncture

245

123

5365

Convexity meningioma, excision of

1040

410

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

5370

C.S.F. Rhinorrhea repair

728

358

5376

Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery

785

410

5377

Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array)

993

410

5380

Glioma biopsy

515

307

5385

Glioma (lobectomy)

1040

358

5390

Glioma (part removal)

1040

358

5400

Hemispherectomy

1040

461

5410

Intra cerebral haemorrhage, open operation

712

307

5415

Intra cerebral and intracerebellar tumours not otherwise listed

973

358

5420

Intracranial abscess (open operation)

758

307

5425

Intracranial abscess (tapping)

490

256

5430

Intraventricular tumours, excision of

1040

358

5435

Leucotomy

490

307

5440

Meningocele, repair of

832

307

5446

Direct lateral cervical puncture of c1 and c2 levels as for cervical myelogram

148

102

5450

Myelomeningocele, repair of

490

307

5455

Other extra cerebral intracranial tumours, excision of

1040

358

5460

Parasagittal meningioma, repair of

1040

358

5465

Pinealoma, excision of

1040

358

5470

Pituitary gland, hypophysectomy all approaches

1008

358

5480

Posterior fossa tumours, removal of

1008

461

5484

Stereotactic computer assisted volumetric intracranial procedure (List separately in addition to code for primary procedure)

122

0

5490

Subdural haematoma (burr hole drainage)

490

256

5495

Subdural haematoma (open operation)

712

307

5500

Subdural tap (infant)

245

123

5505

Tentorial decompression

589

358

5510

Third ventriculostomy

589

358

5515

Torkilsden shunt

589

358

5520

Valve shunt (hydrocephalus)

426

205

5525

Valve shunt revision

392

205

5535

Ventricle puncture (fontanelle)

245

123

5540

Ventriculography (adult)

224

123

5545

Ventriculography (child under 12)

224

154

CRANIAL NERVES:

5555

Acoustic neuroma, removal of

1040

461

5560

Auditory nerve, etc. (section)

589

358

5565

Differential section, facial nerve

441

256

5575

Injection trigeminal branch (peripheral)

99

0

5580

Injection trigeminal division

245

0

5585

Injection trigeminal ganglion

392

0

5590

Intracranial sensory root division (trigeminal)

589

358

5600

Peripheral nerve repairs

392

184

5605

Peripheral nerve tumour, excision of

343

128

5610

Sensory nerve neurectomy

294

123

5611

Rhizolysis, one or more facet joints

196

123

5615

Nerve block for pain control

99

0

5620

Sympathetic block including coeliac ganglion and stellate ganglion

148

0

5621

Intravenous block (Biers technique)

148

0

5622

E.C.T. (each session)

49

51

SCALP:

5630

Cirsoid aneurysm scalp, repair of

490

307

5635

Laceration, suture of (per laceration)

74

72

SKULL:

5645

Burr holes (diagnostic)

515

154

5650

Burr holes (therapeutic)

490

256

5660

Craniotomy

735

358

5665

Depressed skull fracture (dural involvement)

624

256

5670

Depressed skull fracture, (simple) operation for

392

256

5675

Extradural haematoma, evacuation of

540

307

5690

Osteoma calvarium, excision of

490

256

5691

Consultant plastic surgeon cranio facialplasty, including the correction of craniosynostoses and facial synostoses

686

461

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

5692

Consultant neurosurgeon neurosurgical involvement with cranio facialplasty (for Anaesthetist Benefit see 5691)

490

0

5693

Skull bone grafting to facial skeleton

466

256

5695

Platybasia, repair of

1008

461

5700

Skull biopsy

224

123

5705

Skull defect repair

490

307

5710

Subtemporal decompression

441

225

5715

Suture splitting

441

225

SPINAL CORD:

5719

Chemical lumbar sympathectomy

148

0

5725

Anomalies of cord vascular, operation for

1040

410

5730

Cervical disc, partial excision of or fusion

783

256

5731

Cervical disc, excision of two or more levels

991

256

5732

Microneurosurgical subarticular fenestration and foraminal decompression including microdisectomy

672

205

5740

Chordoma (spinal), removal of

1040

307

5745

Cord tumours, removal of

764

358

5746

Dumbbell tumours, transthoracic or abdominal removal

832

358

5755

Haematomyelia, aspiration of

540

256

5756

Intrathecal cytotoxic, chemotherapy infusion

172

77

5760

Lumbar puncture

68

72

5761

Cervical sympathectomy (unilateral)

441

184

5762

Cervical sympathectomy (bilateral)

515

205

5763

Exploration of the brachial plexus with removal of tumours

639

307

5765

Lumbar sympathectomy

441

205

5770

Lumbar sympathectomy (bilateral)

515

225

5771

Nerve root tumours, transthoracic or abdominal removal

490

358

5775

Spinal posterior rhizotomy

441

256

5785

Syringomyelia, aspiration of

572

307

NEUROLOGICAL ASSESSMENT:

5880

EMG

89

0

5881

Electromyography study rectal mucosal sensitivity testing

89

0

5905

Video telemetric EEG recordings including full clinical evaluation and placement of sphenoidal electrodes

343

123

5906

Video telemetric EEG recordings including full clinical evaluation following placement of sub dural electrodes.

245

0

UROLOGY PROCEDURES

KIDNEY:

925

Simple Nephrectomy

441

205

920

Hemi nephrectomy

468

205

921

Radical nephrectomy (includes adrenalectomy and para-aortic lymph nodes)

520

225

926

Radical nephrectomy and caval extension below liver

624

225

927

Radical nephrectomy and caval extension of tumour above liver

832

358

929

Nephroureterectomy including bladder cuff

650

225

930

Nephrolithotomy

624

184

931

Percutaneous nephrolithotomy

312

205

935

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

294

154

940

Pyelolithotomy

490

184

945

Pyeloplasty

540

184

955

Renal biopsy (needle)

89

72

5910

ESWL, one or more sessions per hospital stay or as an outpatient, up to 3 months

294

92

ADRENAL GLANDS:

95

Adrenalectomy (unilateral)

450

205

100

Adrenalectomy (bilateral)

600

205

101

Adrenalectomy for phaeochromocytoma

600

512

106

Neuroblastoma, tru cut biopsy

89

72

107

Neuroblastoma, resection

624

307

TRANSPLANTATION:

923

Kidney transplant

686

410

URETER:

5850

Ureteroscopy, diagnostic, with or without biopsy

150

92

5911

Ureteroscopy & contact lithotripsy with placement/removal of J stent, one or more sessions per hospital stay

343

123

975

Open ureterolithotomy

302

143

981

Ureterolysis (unilateral)

392

143

982

Ureterolysis (bilateral)

624

184

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

983

Ureteric reimplantation, unilateral for reflux, stricture or fistula

468

184

986

Ureteric reimplantation, bilateral for reflux, stricture or fistula

624

184

984

STING procedure (initial)

294

82

987

STING procedure (repeat)

146

72

995

Ureterostomy (unilateral)

294

143

1000

Ureterostomy (bilateral)

441

184

996

Ureteric substitut  ion (with bowel segment)

520

184

BLADDER:

836

Bladder, instillation of anticarcinogenic agent (BCG)

57

72

898

Percutaneous suprapubic cystostomy

62

72

1031

Complex urodynamic evaluation, involving cineradiography

89

72

884

Cystoscopy with or without overdistension, with or without biopsy

83

72

890

Cystoscopy with ureteric catheterisation

104

82

885

Cystoscopy with diathermy to bladder tumour(s)

125

77

887

Cystoscopy with insertion of JJ stent

125

77

881

Cystoscopy with removal of JJ stent

104

72

895

Cystoscopy with or without ureteroscopy and removal of ureteric calculus

196

82

960

Open suprapubic cystostomy

148

72

924

Litholapaxy

294

123

897

Open cystolithotomy

208

92

855

Primary transurethral resection of bladder tumour(s), one or more

364

102

910

Excision of bladder diverticulum

392

154

901

Closure of ruptured bladder (intraperitoneal)

392

154

865

Cystectomy, partial

416

154

875

Cystectomy with ileal or sigmoid conduit and bowel anastomosis

811

358

877

Cystectomy with continent diversion with or without construction of neobladder

936

358

906

Augmentation cystoplasty

624

358

899

Substitution cystoplasty

780

358

5845

Ileal conduit and bowel anastomosis

500

307

4645

Closure of bladder exstrophy

850

358

4691

Young - Dees operation

650

307

902

Bladder, implantation of radioactive sources, simple, one to four sources

120

72

903

Bladder, implantation of radioactive sources, intermediate, five to ten sources

180

82

904

Bladder, implantation of radioactive sources, complex, greater than ten sources

265

92

PROSTATE:

713

Biopsy of prostate (perineal or transrectal)

62

72

711

Electro ejaculation procedure

99

72

907

Bladder neck, transurethral incision of

208

82

850

Bladder neck, transurethral resection of

260

102

700

Transurethral prostatectomy

468

164

708

Open prostatectomy

500

225

701

Radical retropubic nerve sparing prostatectomy (includes bilateral pelvic lymph adenectomy with bladder neck reconstruction and anastomosis to the urethra)

728

333

URETHRA:

1015

Urethral dilatation

49

72

665

Meatotomy

74

72

664

Meatoplasty

196

102

1030

Optical urethrotomy

156

72

666

Urethroplasty for penile or bulbar urethral stricture

392

184

667

Acute repair of rupture of membranous urethra

392

184

668

Urethroplasty for repair of prostatic or membranous urethral stricture, complete procedure

624

256

703

Insertion of an endo urethral stent for urethral stricture

148

72

1032

Implantation of artificial urinary sphincter

490

225

676

Removal of artificial urinary sphincter

208

92

4670

Hypospadias,   fistula closure

294

133

677

Hypospadias-MAGPI procedure

294

133

4675

Hypospadias, reconstruction of urethra

392

154

4660

Epispadias, reconstruction of urethra

392

133

Code

Surgical Procedure

Procedure

Benefit IR£

Surgical

Anaesthetic

4676

One stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap

650

358

MALE GENITAL TRACT:

681

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

49

688

Biopsy of penis

62

72

695

Prepuce, dorsal incision of

74

72

696

Release of priapism (needle drainage)

74

72

683

Circumcision

99

82

686

Chordee release of

196

123

693

Nesbit procedure (plastic operation on penis to correct angulation)

291

133

4681

Insertion of malleable penile prosthesis

294

154

4682

Insertion of inflatable penile prosthesis

416

205

694

Removal of penile prosthesis

291

133

685

Penis, amputation of partial

245

123

687

Penis, amputation of -total

490

225

650

Hydrocele (tapping)

49

655

Hydrocelectomy, bilateral

253

123

660

Hydrocelectomy, unilateral

177

102

698

Excision of epididymal cyst(s) unilateral or bilateral

229

113

645

Epididymectomy, unilateral

198

113

699

Epididymectomy, bilateral

291

123

755

Varicocelectomy

245

123

704

Epididymovasostomy, bilateral

364

184

715

Orchidopexy, unilateral

196

102

720

Orchidopexy, bilateral

244

154

735

Orchidopexy, unilateral for torsion and exploration of opposite side

244

143

740

Testicular biopsy (needle)

68

72

741

Testicular biopsy (open surgical)

134

77

742

Testicular prosthesis, insertion /replacement/removal of, unilateral

196

87

743

Testicular prosthesis, insertion/replacement/removal of, bilateral

244

123

675

Orchidectomy, unilateral

148

102

670

Orchidectomy, bilateral

208

102

672

Drainage of intra-scrotal abscess

62

FEMALE GENITAL TRACT:

2415

Cystocele, repair of

196

128

991

Urethropexy for genuine stress incontinence (Stamey, Raz, Burch, Marshall-Marchetti)

364

123

992

Pubovaginal sling urethropexy

420

164

2465

Vaginal fistula (vesico vaginal), repair of

392

154

4690

Vaginal reconstruction with skin graft

491

205

993

Vesico colic fistula-excision of, and sigmoid colectomy

491

205

MISCELLANEOUS:

820

Arterial venous fistula in arm under L.A.

196

164

821

Gortex graft placement for AV access for dialysis

441

164

822

Permacath Hickman catheter for dialysis

245

123

834

Insertion/replacement of Tenchkoff catheter for dialysis

198

123

838

Removal of Tenchkoff catheter

196

123

LYMPHATICS:

1310

Axillary/inguinal lymph node(s) superficial dissection of

100

92

1320

Axillary or inguinal lymph nodes, incision of abscess

100

72

1326

Deep cervical node excision biopsy (not needle biopsy)

100

72

1315

Axillary lymph nodes complete dissection of

343

123

1335

Inguinal or pelvic lymph node block dissection, unilateral

368

164

1336

Inguinal or pelvic lymph node block dissection, bilateral

550

256

1355

Lymphatic infusion

245

1365

Primary or secondary retroperitoneal lymphadenectomy complete, transabdominal

589

307

TABLE C.3

Code

Radiological Procedure

Procedure

Benefit IR£

Radiological

Anaesthetic

ALIMENTARY TRACT

6000

Plain film, abdomen

22

6001

Plain film abdomen complete, including decubitus and/or erect views

29

SINGLE CONTRAST STUDIES(BARIUM OR WATER SOLUBLE)

6005

Ba. enema

43

6015

Ba. meal

29

6020

Ba. meal and follow through or small bowel study

43

6025

Ba. swallow

29

6060

Small bowel enema

74

6066

Defaecating proctogram

107

DOUBLE CONTRAST STUDIES

6010

Ba. enema, double contrast

75

6011

Ba. enema, therapeutic forreduction of intussusception

107

6021

Ba. meal (double contrast)

43

6030

Ba. swallow and meal

43

6035

Cholecystogram

29

6040

Screening crosbie capsule

29

6045

Screening diaphragm

29

6070

T - tube cholangiogram

29

6055

IV cholangiogram

43

CHEST

6075

Chest and ribs

22

6079

Chest, PA and lateral

22

6080

Chest, PA and lateral with flouroscopy

29

6085

Chest, PA lateral and apical

22

6086

Chest, complete, minimum of four views

29

6090

Larynx

22

6095

Sternum and chest

22

6100

Thoracic inlet

22

C.T. SCANS

6102

Brain, without contrast

85

102

6103

Brain, with contrast material

132

102

6104

Orbit, sella or outer, middle, or inner ear, without contrast (except if done at same time as 6102 or 6103)

85

102

6106

Orbit, sella or outer, middle, or inner ear, with contrast material (except if done at same time as 6102 or 6103)

132

102

6107

Maxillofacial area, without contrast material (except if done at same time as 6102 or 6103)

85

102

6108

Maxillofacial area, with contrast material (except if done at same time as 6102 or 6103)

132

102

6109

Thorax, without contrast material

85

102

6112

Thorax, with contrast material

132

102

6111

CAT scanning for biopsy or drainage

132

256

6113

High resolution, lungs

132

102

6114

Abdomen, without contrast material

85

102

6116

Abdomen, with contrast material

132

102

6117

I.V. dynamic sequential scanning

132

102

6118

I.V. dynamic non-incremental scanning

132

102

SKELETAL

6224

C.T. of spine with contrast material

132

102

6226

Long bones

64

102

6227

Joints

85

102

6228

Spine

85

102

6229

Feet/Hands

85

102

JOINTS AND LONG BONES

6115

Ankle

22

6119

Ankle, complete, minimum of three views including inversion/eversion

29

6121

Acromioclavicular joints, bilateral, with or without weight distraction

29

6122

Knee, complete, including oblique(s), and tunnel, and/or patellar and/or standing views

29

6120

Bone age

29

Code

Radiological Procedure

Procedure

Benefit IR£

Radiological

Anaesthetic

6125

Calcaneum

22

6130

Clavicle

22

6135

Elbow

22

6140

Femur

22

6145

Finger/toe

22

6150

Foot

22

6155

Hand

22

6160

Hip

22

6165

Humerus

22

6170

Knee

22

6175

Limb length/orthopaedicmeasurement

29

6180

Pelvis (inc. hips)

22

6185

Radius and ulna

22

6190

Sacro-Iliac joints

22

6195

Scaphoid

22

6200

Scapula

22

6205

Scoliosis series

22

6210

Shoulder

22

6215

Sternoclavicular joint

22

6220

Tibia and fibula

22

6225

Wrist

22

MAGNETIC RESONANCE IMAGING (M.R.I.)

6230

Magnetic resonance imaging

97

154

6231

Magnetic resonance imaging with contrast enhancement

132

154

NUCLEAR MEDICINE IMAGING

MUSCULO SKELETAL SYSTEM

6270

Limited joint scan

29

6275

Multiple joint scan

43

6280

Sacro-iliac joint uptake

29

6290

Partial body bone scan

29

6295

Whole body bone scan

43

6300

3-Phase bone scan

43

6305

SPECT (tomo) bone scan

61

6340

Gallium scan

43

CENTRAL NERVOUS SYSTEM

6310

Static brain

29

6315

Dynamic brain scan

43

6320

SPECT brain (CBF, ceretec, ECD, blood pool)

61

6325

Static - planar cysternogram

61

6330

SPECT cysternogram

85

CARDIOVASCULAR SYSTEM

6260

Aortogram

29

6265

Arteriogram

29

6360

Angiocardiogram (1st pass)

43

6365

Blood pool scan (MUGA)

61

6370

Exercise blood pool scan (EX. MUGA)

97

6375

Dipyridamole thallium

97

6380

Exercise thallium

97

6385

P.Y.P. infarct scan

43

6390

Anti-myosin scan

43

6395

SPECT anti-myosin scan

61

6400

SPECT thallium

97

6570

Venogram, unilateral

43

6575

Venogram, bilateral

61

GENITOURINARY SYSTEM

6415

Renogram

43

6420

Combined renogram/GFR

61

6425

Captopril renogram

61

6430

Diuretic renogram

61

6435

DMSA renal scan

43

6440

Micturating cystogram

61

Code

Radiological Procedure

Procedure

Benefit IR£

Radiological

Anaesthetic

6445

SPECT DMSA renal scan

61

6550

Testicular scan

43

GASTROINTESTINAL SYSTEM

6235

Abdominal scan (Meckel's)

29

6335

Duodenal/gastric reflux

29

6345

Gastric emptying

43

6350

G.I. bleed

43

6355

G.F.R. (Tc-99m DTPA, Cr-51 EDTA)

29

6525

Oesophageal motility study

43

6450

Colloid liver scan

43

6455

HIDA liver scan

43

6460

SPECT liver scan

61

6465

Hepatic (liver) blood flow

43

6540

Salivary scan

29

6545

Spleen scan

29

RESPIRATORY SYSTEM

6470

Aerosol lung scan

43

6475

Gallium lung scan

43

6480

Lung perfusion scan

43

6485

Lung ventilation scan

43

6490

SPECT lung scan

61

6495

Ventilation/perfusion lung scan

85

ENDOCRINE SYSTEM

6410

Whole body iodine scan

43

6520

MIBG scan

61

6530

Parathyroid scan

43

6555

Technetium scan of thyroid

29

6560

Iodine scan of thyroid

29

6565

Thallium scan of thyroid

29

OTHER SCANS

6255

Cholesterol scan

43

6285

Bile salt malabsorption scan

43

6500

Lymphoscintigram

43

6505

Marrow scan

61

6240

White blood cell scan (WBC)

43

6510

Monoclonal antibody scan-SPECT

61

6515

Monoclonal antibody scan - static

43

6535

Platelet scan

43

NUCLEAR MEDICINE IN-VIVO NON-IMAGING TESTS

GENERAL TESTS

6566

Bile salt absorption (ScHCAT)

29

6567

Bile salt breath test

22

6568

Exchangeable body sodium

29

6569

I-131 Uptake (thyroid uptake)

29

6571

I-131 Therapy (thyroid therapy)

43

6572

Oestrogen receptor assay

22

6573

Red cell survival

29

6574

Red cell mass

22

6576

Schilling test (urine)

29

6577

Schilling test (whole body monitor)

29

6578

Total body water

29

6579

Total body potassium

29

OBSTETRIC

6580

Abdomen

22

6585

Pelvimetry

29

SKULL

6590

Facial bones

22

6595

Foramina optic

22

6600

Internal auditory canals

22

6605

Mandible

22

6610

Mastoid

22

Code

Radiological Procedure

Procedure

Benefit IR£

Radiological

Anaesthetic

6615

Maxilla

22

6620

Nasal bones

22

6625

Nasal sinuses

22

6630

Orbital views

22

6635

Parotid gland

22

6640

Pituitary fossa

22

6645

Skull

22

6650

Temporomandibular joint

29

SOFT TISSUES

6655

F.B. in eye and localisation

29

6660

Mammogram

43

6665

Soft tissue neck

22

SPECIAL PROCEDURES

6675

Angiogram (direct puncture, single vessel study, branchial, femoral) includes introduction of needles or catheter injection of contrast media and necessary pre and post injection care specifically related to the injection procedure

97

6680

Angiogram (selective catheter, single/multiple vessel study, coeliac, mesenteric, renal, subclavian etc) includes introduction of needles/catheter injection of contrast media and necessary pre & post injection care specifically related to injection procedure

132

6681

Single selective carotid angiography and/or vertebral study

142

6682

Bilateral carotid angiography study

245

6683

Bilateral carotid angiography and vertebral study

368

6685

Aortogram (arch/TLA, etc.)

97

6690

Cavernosogram

97

6705

Facet arthrogram (single level)

61

6706

Hepatic needle puncture/ catheterisation for biliary procedures

132

6710

Portogram

85

6720

Orbital venogram

85

6721

Spinal arteriogram

442

6725

Splenoportogram

85

6730

Venous sampling - adrenal, parathyroid, renal, etc.

132

6735

Venogram, peripheral, single limb

61

6740

Venography (selective, catheter, single vessel study and/or venous sampling, I.V.C., S.V.C., adrenal, renal, hepatic)

132

SPINE

6745

Cervical

22

6750

Coccyx

22

6755

Complete spine

29

6760

Dorsal (thoracic)

22

6765

Lumbar

22

6770

Sacrum

22

6775

Scoliosis views

29

6780

Skeletal survey

43

TEETH

6785

Occlusal (Intra-Oral)

22

6790

Pantomogram

29

6795

Tooth, single

22

6800

Total Upper and Lower Jaw

29

ULTRASOUND

6805

Biliary

29

6810

Breast

29

6811

Chest

43

6825

Doppler (carotid, cerebral, peripheral, abdominal, renal, etc.)

61

6835

Eye

29

6840

Hip

43

6841

Knee

43

6845

Obstetrical

29

6846

Obstetrical (with full foetal assessment)

61

6850

Paediatric cranial

61

6855

Pelvic

43

Code

Radiological Procedure

Procedure

Benefit IR£

Radiological

Anaesthetic

6856

Parotid gland

43

6857

Pleural space (for localisation)

43

6860

Prostate - transrectal

61

6865

Renal (kidneys)

43

6870

Shoulder

43

6875

Testicular

43

6880

Transvaginal

61

6885

Thyroid

29

6890

Upper abdominal (includes liver, pancreas, aorta and kidneys)

61

6895

Ultrasound guidance during investigations or therapeutic procedure

85

URINARY TRACT

6905

Cystogram

43

6910

I.V.P.

43

6915

Micturating cystogram

43

6920

Straight renal tract (KUB)

22

6925

Urethrogram

43

6930

Vesiculogram

43

OTHERS

6950

Antegrade pyelogram

61

6955

Arthrogram

61

6960

Bronchial brushing

97

6965

Bronchogram

61

6970

Dacrocystogram

43

6975

Discogram

85

6985

Hysterosalpingogram

43

6990

Laryngogram

43

6995

Lymphangiogram

132

7000

Myelogram

85

7005

Myelogram (direct lateral puncture, thoracic or cervical)

132

7010

Needle biopsy (trans-thoracic, bone, abdominal)

85

7011

Nephrostogram

61

7020

Percutaneous transhepaticcholangiogram

85

7025

Per-operative cholangiogram

43

7034

Imaging supervision, interpretation and report for injection procedures during cardiac catheterisation; ventricular and/or atrial angiography

36

7036

Radiological guidance during investigations or therapeutic procedure (use code 7034 for cardiology procedures)

85

7037

Radiological guidance for mammographic wire guided biopsy

36

7040

Retrograde pyelogram

43

7051

Sialgram, Parotid

64

7052

Sialogram, Submandibular

86

7055

Sinogram

29

7065

Tomograms (+ area films)

29

7070

Ventriculogram

85

THERAPEUTIC/INVASIVEPROCEDURES

Please note that therapeutic/invasive procedures are listed in Table C.2

TABLE C.4

Code

Pathological Investigation

Procedure Benefit IR£

8900

CATEGORY 1

17

HAEMATOLOGY

APTT, PT+INR, Blood Gp+uncomplicated crossmatch, Cold Aggluts,

FBC without film, HbH, (in)/direct Coomb's test, Monospot.

BIOCHEMISTRY

Single analytes

IMMUNOLOGY

a-1—AT, C3, C4, Igs, RA Screen, Thyroid Abs

MICROBIOLOGY

Pregnancy test, Stool O/B

CATEGORY 1(A)

17

HAEMATOLOGY

9230

Coag. Factor Assay

8930

Ferritin

8910

Fibrinogen

8935

Iron

9220

RBC autohaemolysis

9215

RBC osm frag.

9225

Platelet Aggregation

8920

Protein C

BIOCHEMISTRY

9185

All nuclear medicine in-vitro investigations (except for those investigations listed in category 5)

All Profiles:

Biochemical Investigations of,

9000

-Renal (one or more)

9005

-Hepatic (one or more)

9010

-Cardiac (one or more)

9015

-Thyroid (one or more)

9020

-Bone (not PTH) (one or more)

9025

-Lipids (one or more)

9310

Biochemistry of hypertension

9165

GTT

9165

HbA1C

9166

Drug levels (including RIA)

9167

HPLC

IMMUNOLOGY

9285

Allurgens

9168

Caeruloplasmin

9169

CRP

9171

Cryoglobulins

9275

IgE

9172

PFB

8945

Streptolysin

8936

Transferrin

ENDICRINOLOGY

8937

Hormone Levels(except for those investigations listed in Category 5)

CATEGORY 3

7

HAEMATOLOGY

8905

FBC + manual film ± eosinophil count

9040

Kliehauer

8915

LAP

9035

Reticulocyte count

MICROBIOLOGY

8970

MSU + culture

9045

Stool O+P

BIOCHEMISTRY

9030

Sweat investigation

IMMUNOLOGY

9050

IF - single antibody e.g. ANF (except if this investigation gives rise to the investigations listed in Categories 4 or 5)

CATEGORY 4

13

BIOCHEMISTRY

9160

All electrophoresis|serum, lipoprotein, urine

9175

CSF including oligoclonal bands

9180

Myeloma Screen including electrophoresis

9181

Trace metals

9182

Vits A & E

HAEMATOLOGY

9205

Ab indentification (transfusion)

9200

Bleeding time

8925

HbA2

9210

Hb electrophoresis

9226

Thrombophilia screen - this consists of three or more of the following items:

Antithrombin 3, protein C, protein S, factor 7, factor 12, platelet aggregation (spontaneous, second wave of aggregation with weak ADP, and response to dilutions of epinephrine)

8940

U. haemosiderin

9507

Flow cytometry

MICROBIOLOGY

9100

Interpretive review of culture result from wounds, joint fluids,sputum, intestine and other body sites including 1 TB Culture

Code

Pathological Investigation

Procedure Benefit IR£

9385

Interpretative review of viral, bacterial or fungal serology or viral culture

9202

Antibiotic assay - maximum payable, any combination, three per claim

9203

MBC - maximum payable, any combination, three per claim

9204

MIC - maximum payable, any combination, three per claim

9206

Cidal levels

9207

Toxin levels

IMMUNOLOGY

9221

ANCA-for single antibody

9222

AGBM-for single antibody

9280

Gel electrophoresis

9223

HIV, VD or Hepatitis screen

9224

Teicoic acid

9228

Cardiolipin

9227

CH50-functional assay

ALL DISCIPLINES

9694

Gene rearrangement studies

CATEGORY 5(A)

27

BIOCHEMISTRY

9301

- Diabetic KA/hyperosmolar coma

9302

- Acute Renal failure

9303

- Acute hepatic failure

9306

- Porphyria investigation

9308

- Diabetes insipidus

ENDOCRINOLOGY

9304

- Dynamic endocrine function tests (IST, Synact, TRH, Dex supp)

9307

- Full endocrinological investigation of infertility

9309

- Full investigations for inborn errors of metabolism in paediatric patients.

Benefit is only payable once per patient at time of initial investigation (diagnosis).

CATEGORY 5 (B)

27

HISTOPATHOLOGY

9360

Small (1-2 blocks) include cytology and neuropathology

MICROBIOLOGY

9381

Interpretive review of culture of CSF, blood

IMMUNOLOGY

9391

Infertility screen

9270

Paraprotein typing

9392

IF - autoantibody screen and/or DNA Abs and/or subtyping

9605

Immune complex assays (except for those investigations listed in Category 1)

All DISCIPLINES

9393

Polymerase chain reaction

CATEGORY 6

40

HAEMATOLOGY

9501

Marrow aspirate (except immunocytochemistry)

9502

Marrow trephine

HISTOPATHOLOGY

9530

Medium (e.g. description + 3-5 blocks)

9540

Colonoscopic series

9550

Clinical (i.e. non screening) cytology (not including smear + section)

9535

Lymph node

9545

Parathyroid

IMMUNOLOGY

9503

HLA typing

MICROBIOLOGY

9504

Immunofluorescence

9506

Electron microscopy

CATEGORY 7

73

HISTOPATHOLOGY

9601

Liver, renal biopsies including special stains

9602

Fine needle aspiration biopsy, cell block and smear done together

9650

Large (5 + blocks and all major dissections)

9651

Breast screening, localisation segments with review of radiographs

HAEMATOLOGY

9603

Marrow aspirate and trephine done together

IMMUNOLOGY

9670

IF-frozen section direct or indirect

9610

WBC function tests

CATEGORY 8 (A)

96

HISTOPATHOLOGY

9693

Frozen section or rapid intraoperative diagnosis

9691

Immunohistology (include fluorescence)

CATEGORY 8 (B)

96

HAEMATOLOGY

9505

Immunocytochemistry

9700

CATEGORY 9

39

All tests associated with Obstetrics, including normal delivery, caesarean section and miscarriage

SCHEDULE D

RISK EQUALISATION CALCULATIONS

1. The period (referred to in this Schedule as the "specified period") in respect of which the calculations specified in this Schedule are to be carried out shall be a period determined in accordance with article 7 of this Scheme.

2. General Definitions

"claim group" means in respect of a settled hospital claim any previous claim which is either

(a) a linked claim of that claim; or

(b) is a constituent of or gave rise to a previous claim group which includes a claim which is so linked provided that no claim may be included in a claim group more than once;

"covered persons" means in relation to a scheme undertaking

(a) fully insured persons who on the last day of a specified period were named in a health insurance contract effected by that scheme undertaking and who belonged on that day to a specified cell or combination of cells, or

(b) fully insured persons not already included under paragraph (a) of this definition who were formerly named in a health insurance contract effected by that scheme undertaking and who, but for the cessation of their health insurance contract, would have belonged to that cell or those cells on the last day of that period;

"current claim" has the meaning assigned to it under the definition of linked claim;

"first day" means in relation to a settled hospital claim either, as appropriate,

(a) the day upon which the hospital stay to which a settled accommodation claim relates commenced; or

(b) the day of the provision of outpatient services to which a settled out-patient claim relates;

"last day" means in relation to a settled hospital claim either, as appropriate,

(a) the day upon which the hospital stay to which a settled accommodation claim relates ceased; or

(b) the day of the provision of outpatient services to which a settled outpatient claim relates;

"linked claim" means 'in respect of a settled hospital claim (referred to in this Schedule as the "current claim") a previous settled hospital claim relating to the same fully insured person (referred to in this Schedule as the "previous claim") which satisfies one or more of the following conditions

(a) that the first day of the previous claim

(i) is after or coincides with the first day of the current claim; and

(ii) is before or not more than seven days after the last day of the current claim; or

(b) that the last day of the previous claim

(i) is before or coincides with the last day of the current claim; and

(ii) is after or not more than seven days before the first day of the current claim; or

(c) that the first day of the previous claim is before the first day of the current claim and the last day of the previous claim is after the last day of the current claim.

"weighted claim value" means, for a settled hospital claim

(a) if that claim is a settled accommodation claim

(i) a value determined in accordance with the following table

Total number of in-patient days in respect of the hospital stay to which that claim relates

Value

1

0.20

2

0.30

3

0.40

4

0.50

5 or more

1.00

or as appropriate

(ii) a value calculated in accordance with the following formula

0.20 x Y

where Y is the total number of day- patient days in respect of the hospital stay to which that claim relates,

(b) if that claim is a settled out-patient claim 0.10

(c) the value determined in accordance with paragraphs (a) or (b) as appropriate in respect of that claim shall be reduced by an amount calculated in accordance with the following formula

Z - 1

where Z is the greater of

(i) one; and

(ii) the sum of

(A) the value determined in accordance with paragraphs (a) or (b) as appropriate; and

(B) the sum of the weighted claim values for the claim group associated with the claim;

"specified period" has the meaning assigned to it by paragraph 1 of this Schedule;

"previous claim" has the meaning assigned to it under the definition of linked claim;

"previous claim group" means a claim group given rise to by a previous claim.

3. Cell Definitions (with respect to a specified period, a specified scheme undertaking and a specified cell)

"cell day-patient days" means the sum of all day-patient days in respect of settled accommodation claims which acquired that status during that period in respect of covered persons;

"cell insured population" and "CIP" means the sum of

(a) the total number of fully insured persons in that cell on the first day of that period, and

(b) the total number of fully insured persons in that cell on the first day of the next following period

with the result being divided by two;

"cell equalised benefits" and "CEB" means the sum of all prescribed equalised benefits paid, in respect of settled claims which acquired that status during that period, to or on behalf of covered persons;

"cell weighted claim value" and "CWCV" means the sum of all weighted claim values, in respect of settled hospital claims which acquired that status during that period, in respect of covered persons;

"cell equalised benefits average" and "CEBA" means an amount determined in accordance with the following formula

/images/si084y96p0083.gif

4. Scheme Undertaking Definitions (with respect to a specified period and a specified scheme undertaking)

"undertaking insured population" and "UIP" means the sum for all cells of

CIP

"undertaking equalised benefits" and "UEB" means the sum for all cells of

CEB

"undertaking adult lives" and "UAL" means the sum, for all cells other than the cell or cells which comprise, the prescribed age band "age 17 and under", of

CIP

"undertaking child lives" and "UCL" mean the value, for the cell or cells which comprise the prescribed age band "age 17 or under", of

CIP

"undertaking equivalent adult lives" and "UEAL" means a value determined in accordance with the formula

/images/si084y96p0084a.gif

"undertaking equivalent adult ratio" and "UEAR" means a value determined in accordance with the formula

/images/si084y96p0084b.gif

5. Market Specific Definitions (with respect to a specified period)

"market insured population(cell)" and "MIP(Cell)" means the sum, for all scheme undertakings for a specified cell, of

CIP

"market insured population(total)" and "MIP(Total)" means, the sum, for all cells, of

MIP(Cell)

"market equalised benefits(cell)" and "MEB(Cell)" means the sum, for all scheme undertakings for a specified cell, of

CEB

"market equalised benefit(total)" and "MEB(Total)" means the sum, for all cells, of

MEB(Cell)

"market weighted claim value" and "MWCV(Cell)" means the sum, for all scheme undertakings for a specified cell, of

CWCV

"market equalised benefits average" and "MEBA(Cell)" mean an amount, for a specified cell, calculated in accordance with the formula

/images/si084y96p0086a.gif

"market utilisation" and "MU(Cell)" means a value, for a specified cell, calculated in accordance with the formula

/images/si084y96p0086b.gif

"market proportion" and "MP(Cell)" means a value calculated in accordance with the formula

/images/si084y96p0086c.gif

"market equivalent adult lives" and "MEAL" means, the sum for all scheme undertakings of

UEAL

"market equivalent adult ratio" and "MEAR" means a value determined in accordance with the formula

/images/si084y96p0087.gif

6. With respect to a specified period, a specified scheme undertaking and a specified cell

"cell standardised benefits" and "CSB" mean an amount calculated in accordance with the formula

CEBA x MP(Cell) x MU(Cell) x UIP

provided that if for that cell the CWCV is less than 10, CSB instead shall be calculated in accordance with the formula

MEBA(Cell) x MP(Cell) x MU(Cell) x UIP

7. With respect to a specified period and a specified scheme undertaking

"undertaking standardised benefits - first calculation" and "USB1" means the sum for all cells of

CSB

"undertaking standardised benefits - second calculation" and "USB2" means a value determined in accordance with the formula

/images/si084y96p0088.gif

8. With respect to a specified period

"market standardised benefits" and "MSB" means the sum, for all scheme undertakings, of

USB2

9. With respect to a specified period and a specified scheme undertaking

"undertaking standardised benefits" and "USB" means an amount determined in accordance with the formula

/images/si084y96p0089.gif

10. The contribution (to be known for the purposes of this Scheme as the "equalisation contribution") for a specified period for a scheme undertaking shall be determined in accordance with the formula

USB - UEB

SCHEDULE E

Quarter ending ......................... Gender ............. Scheme Undertaking....................

Cell

Number of fully insured persons on first day of that quarter

Number of fully insured persons on first day of the next following quarter

Cell equalised benefits for that quarter

Cell weighted claim value for that quarter

Cell day-patient days for that quarter

Number of settled out-patient claims in respect of covered persons for that quarter

Number of settled in-patient claims in respect of covered persons for that quarter

Total

Which relate to one in-patient day only

Which relate to two in-patient days only

Which relate to three in-patient days only

Which relate to four in-patient days only

Which relate to five in-patient days only

Which relate to six in-patient days only

Which relate to six in-patient days only

Which relate to six in-patient days only

Which relate to seven in-patient days only

Which relate to eight in-patient days only

Which relate to nine in-patient days only

Which relate to ten in-patient days only

Which relate to not less than eleven and not more than fifteen in-patient days

Which relate to not less than sixteen and not more than twenty in-patient days

Which relate to not less than twenty one and not more than thirty in-patient days

Which relate to thirty one or more in-patient days

Age 17 and under

Age 18 to age 29

Age 30 to age 39

Age 40 to age 49

Age 50 to age 59

Age 60 to age 69

Age 70 to age 79

Age 80 and over