E495

PDF page 625 / N45

Degenerative Diseases of the Knee
  # R687 Knee arthroscopy set-up, degenerative disease of the knee.
           Includes when rendered for synovial biopsy and/or resection
           or trimming of plica .............................................................                    6         97.35       7
      Non-Degenerative Disorders of the Knee or Acutely Locked Knee
  # R699 Knee arthroscopy set-up, non-degenerative disorders of the
            knee or acutely locked knee. Includes when rendered for
            synovial biopsy and/or resection or trimming of plica.........    6        97.35      7
       Payment rules:
       1.A knee procedure listed in the Knee section of the Schedule performed arthroscopically is
         eligible for payment in addition to R687 or R699 if that procedure is not described as a
         component of R699 or described by an E-add-on code to R699.
                                          2.Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R687 or
                                            R699 when the service described by the E-code is a generally accepted component of a
                                            procedure described in Payment Rule #1.
                                          3.E476 is not eligible for payment with R687 or R699 unless there is:
                                              a.evidence of an intra-articular loose body causing mechanical symptoms; or
                                              b.a symptomatic loose screw.
                                          4.E-codes from the arthroscopy section other than E494, E495 and E476 are not eligible for
                                            payment with R687.
                                          5.Except where prior approval has been given by a MOH medical consultant, E494 and E495
                                            are not eligible for payment with R687 unless all of the following criteria are met:
                                              a.Kellgren-Lawrence knee osteoarthritis grade less than 3 as documented on standing
                                                knee x-rays performed within the last 12 months; and
                                              b.Unstable chondral pathology or meniscal tear causing mechanical symptoms which have
                                                not responded to a minimum of six months active non-surgical treatment.
                                          6.R687 is eligible for payment in all patients with degenerative disease when a diagnostic
                                            arthroscopy is required prior to or in conjunction with reconstructive proximal tibial or distal
                                            femoral osteotomy.
                                          [Commentary:
                                          1.R687 is an uninsured service for any of the following:
                                              a.arthroscopic lavage of the knee alone (without debridement) for osteoarthritis;
                                              b.when the criteria in payment rule 5 are not met and no other arthroscopic E-add-on codes
                                                are medically necessary; or
                                              c.when prior approval of R687 and E494 or E495 is denied by the ministry.
                                          2.Arthroscopic lavage of the knee alone (without debridement) is not recommended for any
                                            stage of osteoarthritis.
                                          3.The routine use of debridement for treatment of osteoarthritis of the knee is not
                                            recommended by the Ontario Health Technology Advisory Committee (OHTAC). See https://
                                            www.hqontario.ca/Portals/0/Documents/evidence/reports/recommendation-update-
                                            arthroscopic-debridement-1411-en.pdf

PDF page 626 / N46

MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
KNEE
                                                                              Asst      Surg     Anae
         4.Prior approval may be granted for E494 or E495 in patients with Kellgren-Lawrence grade 3
           or 4 osteoarthritis (see Kohn MD, Sassoon AA, Fernando ND. Classifications in brief:
           Kellgren-Lawrence classification of osteoarthritis. Clin Orthop Relat Res. 2016 Aug;
           474(8):1886-93) if the clinical record supports:
            a.Significant functional impairment caused by an unstable articular chondral flap or
               degenerative meniscal tear which has not responded to a minimum of six months active
               non-surgical treatment; and
            b.the patient is not a current candidate for knee realignment or arthroplasty.]
# E476 Removal of symptomatic loose body(ies) and/or screw ... add                                                 192.00
      Note:
      Removal of iatrogenic loose body(ies) is not eligible for payment.
# E491 Lateral release .................................................................. add                      161.45
# E492 Synovectomy - for diseased synovium, anterior, posterior or
         complete....................................................................... add                       231.30
# E493 Drilling of defect (includes removal of loose body(ies) ..... add                                           251.55
# E478 Pinning of osteochondral fragment ................................... add                                   251.55

PDF page 626 / N46

Note:
         F-prefix fracture procedures are not eligible for payment with E478 for the same fracture.
# E494 Debridement (degenerative cartilage) – substantial
         debridement of 1 or more focal flaps of unstable
         degenerative articular cartilage causing mechanical
         symptoms, includes, when rendered, synovectomy,
         meniscal trimming and/or chondroplasty...................... add                                          299.00
# E498 Debridement (trauma) - substantial debridement of 1 or more
         focal flaps of unstable post-traumatic articular cartilage
         causing mechanical symptoms, includes, when rendered,
         synovectomy, meniscal trimming and/or chondroplasty add                                                   299.00
         Payment rules:
         1.E492 is not eligible for payment in addition to E494 or E498.
         2.E498 is not eligible for payment with R687 or E494.
         3.E494 or E498 are not eligible for payment for the debridement of cartilage flaps for the
           purpose of surgical visualization alone.
         [Commentary:
         When E494 or E495 are claimed with R687, or E498 is claimed with R699 it is recommended
         that the intra-articular pathology be documented with pre- and post-procedural photographic
         images taken during arthroscopy which are archived in the permanent medical record where
         possible.]
# E489 Microfracture and/or abrasion arthroplasty, for cartilage
         deficiency (includes removal of loose body(ies)........... add                                            250.00
# E495 Meniscectomy, partial or total, for symptomatic meniscal tear
         ..................................................................................... add                 240.45

PDF page 627 / N47

MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
 KNEE
                                                                                                        Asst   Surg     Anae
# E496 Repair medial or lateral meniscus, includes when rendered
           debridement of attachment site .................................... add  336.65
      Note:
      1.E495 is not eligible for payment in addition to E496 for the same meniscus.
      2.Trimming of a meniscus does not constitute E495 or E496.
      3.E489 and/or E494 and/or E498 are not eligible for payment in addition to E496 for
        debridement of attachment site.
    ARTHROTOMY
# R412 Knee - with or without removal of loose body .........................                            6     207.90    7
# R413 Osteochondritis dissecans with drilling and/or internal fixation                                  6     267.25    7
       ASPIRATION
        See Diagnostic and Therapeutic Procedures - Injections or Infusions.
    BIOPSY
    Bone/joint
  Z870 - needle.................................................................................               120.70    6
# Z242 - open ...................................................................................        6     193.00    7
    Soft tissue
# Z228 - open ...................................................................................               97.35    6
  Z219 Muscle needle biopsy, soft tissue, per site .............................                                34.05
    DENERVATION/DECOMPRESSION
# R426 Denervation of knee, by open surgical exposure....................                         6            258.00    7
      [Commentary:
      For Denervation/Decompression of peripheral nerves see page X12-X13.]

Master, record 1192. Record Layout PDF, page 1.

E49520250401999999990000240450000000000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.