R993

PDF page 26 / GP12

Independent Consideration (IC)
Services listed in the Schedule without specified fees are identified as “IC” and are given independent
consideration by the medical consultant. Claims for such services must be submitted with a
supporting letter explaining the amount of the fee claimed, and must include an appropriate operative
or consultation report, and a comparison of the scope and difficulty of the procedure in relation to non-
IC procedures in the Schedule. For treatment of tumours not listed in the Schedule, surgeons must
use the IC code, R993, and for surgical procedures not listed, but similar to a listed service, the code,
R990.

PDF page 546 / SP4

SURGICAL PREAMBLE
PREAMBLE
 9. Unless otherwise stated, the listed benefits are for unilateral procedures only.
 10. When a procedure is performed, a procedural benefit, if listed, should be claimed. Substitution
     of consultation and/or visit benefits for procedural benefits (except as in paragraph 11), is not in
     keeping with the intent of the benefit schedule.
 11. When a surgical benefit (non-IOP, Complete Care, Fracture or Dislocation) is less than the
     surgical consultation benefit, and the case is referred, a physician may claim a surgical
     consultation benefit instead of the surgical benefit. However, to avoid the consultation being
     counted as such under the Ministry of Health limitation rules on the number of consultations
     allowed per year, the physician should claim the consultation fee under the surgical procedure
     nomenclature or code. Since the consultation is replacing a procedural benefit which includes
     the pre- and post-operative and surgical care, no additional claims beyond the consultation
     should be made.
 12. If a physician performs a minor surgical procedure and during the same visit assesses and
     treats the patient for another completely unrelated and significant problem involving another
     body system, the physician should claim for the procedure as well as the appropriate
     assessment.
 13. Where a procedure is listed with a “Z” code, the procedure is an “Independent Operative
     Procedure (IOP)”. If the major pre-operative visit is rendered in the previous 12-month period
     prior to the IOP service by the same physician, only the following assessment services are
     eligible for payment on the same day prior to the IOP service:
    a. a minor assessment if rendered by a General and Family Physician; or
    b. a partial assessment if rendered by a specialist.
     When the major preoperative assessment is rendered on the same day as the IOP, no other
     consultation or assessment is eligible for payment if rendered prior to the IOP service by the
     same physician on the same day.
     When multiple or bilateral IOP are performed at the same time by the same physician, the
     listed procedural benefits should be claimed in full but the pre- and post-operative benefits
     should be claimed as if only one procedure had been performed.
      When an IOP service is rendered on the same day as a non-IOP service by the same
      physician, the hospital or day care admission assessment (consultation, repeat consultation,
      general or specific assessment or re -assessment, partial assessment) may not be claimed by
      the surgeon unless it happens to be the major preoperative visit as defined on GP4.
 14. When procedures are specifically listed under Surgical Procedures, surgeons should use these
     listings rather than applying one of the plastic surgery listed fees under Skin and Subcutaneous
     Tissue in the Integumentary System Surgical Procedures section of this Schedule.
 15. For excision of tumours not specifically listed in this Schedule, claims should be made on an IC
     basis (code R993). Independent Consideration also will be given (under code R990) to claims
     for other unusual but generally accepted surgical procedures which are not listed specifically in
     the Schedule (excluding non-major variations of listed procedures). In submitting claims,
     physicians should relate the service rendered to comparable listed procedures in terms of
     scope and difficulty (see General Preamble GP12).

Master, record 5183. Record Layout PDF, page 1.

R99320260401999999990000000000000000000000000000000000000000000000000000000

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.