R117

PDF page 569 / M19

B. Full thickness grafts
# R092 Minor - less than 1 cm average diameter ...............................                 116.65 7
# R093 Intermediate - 1 cm to 5 cm average diameter .......................                  6 178.90 7
# R083 Major - over 5 cm.................................................................... 6 280.15 7
# R091 Complex - eyelid, nose, lip, face.............................................        6 263.95 7
     Note:
     1.R092, R093, R083, R091 - The medical record must demonstrate the appropriateness of
        codes claimed relative to size of graft.
     2.Skin grafts are not eligible for payment in addition to R117.
# R057 Appendage or tissue re-vascularization involving
         microanastomosis with or without micro neuroanastomosis
         (see General Preamble GP12)...........................................                     I.C    I.C      I.C
# R058 Revision of above (see General Preamble GP12)..................                              I.C    I.C      I.C

PDF page 575 / M25

Mastectomy - female (with or without biopsy)
  # R108 - simple ................................................................................. 6 330.00                     7
    E517    - with immediate postmastectomy superficial chest wall
              reconstruction, to R108...................................... add 30%
  # R117 - skin sparing mastectomy performed with immediate breast
            reconstruction for malignancy or prophylaxis in high-risk
            female patients ...................................................................     6 495.00                     7
    E486    - with nipple sparing, to R117............................... add 30%
  # E505    - with limited axillary node sampling, to R108 or R117 add                                178.05
        Payment rules:
        1.E517 is only eligible for payment when the surgeon has performed and documented:

PDF page 576 / M26

INTEGUMENTARY SYSTEM SURGICAL PROCEDURES
OPERATIONS OF THE BREAST
                                                                        Asst       Surg       Anae
          a.extensive undermining for local advancement flaps >10cm to obliterate inferior or lateral
            excess flap deformities associated with simple mastectomies, or
          b.modified M-plasty or fishtail closure
       Note:
       Skin grafts are not eligible for payment in addition to R117.
     [Commentary:
     For patients who have been approved by OHIP for mastectomy related to sex-reassignment
     surgery, the following fee codes may apply for mastectomy depending on the technique:
     1.R108 - Mastectomy simple + R120 for nipple preservation and grafting.]
# R109 Mastectomy, radical or modified radical (with or without biopsy) 6      780.00      7
     [Commentary:
     Skin grafts are eligible for payment in addition to R109.]
    Mastectomy - male (benign)
      Unilateral - for treatment of adolescent gynecomastia, gynecomastia secondary to endocrine or
      genetic disorders (e.g. Klinefelter's Syndrome) or chemotherapy. Prior approval is not required.
      Removal of male breast fat tissue by liposuction is not an insured service.
# R146 - simple ................................................................................. 6 177.50 7
# R147 - subcutaneous with nipple preservation ..............................                     6 273.95 7
    Mastectomy - male
      Unilateral - for treatment of pathological male breast disease (with or without biopsy), e.g.
      carcinoma
# R148 - simple ................................................................................. 6 311.95 7
# R149 - subcutaneous with nipple preservation ..............................                     6 273.95 7
# E505     - with limited axillary node sampling, to R148 or R149 add                               178.05
    Oncoplastic Breast Surgery
# R102 Level 1 oncoplastic breast conserving lumpectomy or partial
           mastectomy for malignancy................................................             6 350.00 7
# R158 Level 2 oncoplastic breast conserving lumpectomy or partial
           mastectomy for malignancy................................................             6 547.45 7
# E505    - with limited axillary node sampling, to R102, R158 or
             R159 .......................................................................... add   178.05
# E525    - after localization with mammographic wire or radioactive
             seeds, to R102, R158 or R159 .................................. add                    48.05
# E546     - with axillary node dissection up to the level of the axillary
             vein, to R102, R158 or R159 ...........................................               388.75
# R159 Level 3 oncoplastic breast conserving lumpectomy or partial
           mastectomy for malignancy................................................             6 701.15 7
      Payment rules:
      1.R102 is only eligible for payment when
         a.resected breast volume is <= 15% of ipsilateral breast parenchyma, and
         b.the operative report documents dual plane undermining and lumpectomy defect closure
      2.R102 includes nipple undermining, nipple-areolar complex elevation or centralization, skin
        resection and glandular advancement if performed.

Master, record 4372. Record Layout PDF, page 1.

R11720260401999999990000495000000000774600000000000000000111720000001117200

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.