Additional Surgical Services – Rule of Application 29

Additional Surgical Services provided following major surgery are governed by Rule of Application 29 which states:

Benefits for Additional Surgical Services which are performed within three (3) weeks of, but not directly related to a preceding surgery, shall be paid at 100% of the fee. For complications requiring surgery, however, benefits will be based on the nature of the service performed, and its relation to prior surgery, and on the submission of a Special Report.

This rule applies only during the three (3) week postoperative period following an initial major surgical service when provided by the same surgeon or his delegate.

Claims for additional surgical services must include a special report indicating the nature of the work performed.  This special report will be reviewed by a Manitoba Health medical assessor who will consider the relationship of the additional surgery to the initial surgery.

Notwithstanding Rule of Application 29, if the additional surgery is specifically for a postoperative service i.e., tariff 2155 Thoracotomy for postoperative bleeding following lung or esophageal surgery, payment is to be made at 100% of the listed fee and no special report is required.

If it is determined that the additional surgery is unrelated to the initial surgical service, then the full fee for the subsequent surgical service is payable.  If the additional surgery is related, Manitoba Health may reduce the payment, or make no payment, for the additional surgical service.  Occasionally, the listed fee for the additional surgical service may be higher than the fee for the initial surgical service.  In this situation Manitoba Health may elect to pay the full fee for the additional surgical service and reduce the fee for the initial surgical service.

If you are not satisfied with the medical assessor’s determination you may query this assessment and, ultimately, refer the dispute to a Board of Arbitration.  However, it is recommended that you first contact Doctors Manitoba to discuss your concern.

Billing Notes

If the additional surgical procedure is also categorized as a “major” surgical service, but determined to be unrelated, it should be paid at 100% and the inclusive postoperative care period reset to three (3) weeks from the date of this additional surgery.

If the additional surgery is determined to be related (i.e., fee is reduced) the inclusive postoperative care period remains unchanged.

If the additional surgery occurs after the 3-week inclusive postoperative period, Rule of Application 29 does not apply. Payment for the additional surgical service will be made at the listed fees in accordance with the usual surgical Rules of Application

 

Questions?

Ian Foster
ifoster@docsmb.org
(204) 985-5854

 

Updated: November 2016