M016 – Repair of septal perforation
OHIP Ophthalmology Code — RESPIRATORY SURGICAL PROCEDURES · Schedule of Benefits
`M016` is a surgical procedure. The fee for this service includes the required pre-operative and post-operative care. According to the Surgical Preamble (:529), this includes pre-operative hospital visits one or two days before surgery and post-operative care for up to two weeks. The major pre-operative assessment where the decision to operate is made is separately payable (:530). The service requires the use of a suffix to denote the role of the provider: 'A' for the surgeon and 'C' for the anaesthetist (:24). Assistant services (suffix 'B') are not eligible for payment for M016 as per the Schedule of Benefits. If an assistant is required, payment may be considered on an IC basis using fee code M400B with a letter from the surgeon outlining the reason (:99).
When to Use
- Use M016 for the surgical repair of a symptomatic nasal septal perforation resulting from trauma, disease, or previous surgery.
- Use M016 when performing reconstructive surgery to restore nasal function or integrity, provided the procedure is not purely cosmetic or aesthetic.
Common Pitfalls
- Billing for an assistant using suffix 'B' is not permitted; claims will be rejected unless submitted as an IC claim under M400B with supporting documentation.
- Attempting to bill routine post-operative visits (e.g., C122, C123) within the 14-day post-operative period is a common error that will lead to automatic rejection.
- Failing to document the Injury Severity Score (ISS) in the medical record when claiming the E420 trauma premium will result in audit recovery.
Billing Tips
- If performing the procedure via an external approach using transverse columellar and rim incisions with elevation of the nasal tip skin flap, remember to add the E642 premium to your claim.
- Ensure the major pre-operative assessment where the decision to operate was made is billed separately, as it is not included in the M016 surgical fee.
Effective: April 1, 2025
P. Respiratory Surgical Procedures
RESPIRATORY SURGICAL PROCEDURES
Surgical
Integumentary System Surgical Procedures
All insured services must be documented in appropriate records that establish the service was provided, is the service submitted, and was medically necessary.
The listed benefit is for a unilateral procedure unless otherwise stated. (From `:532`)
The surgical benefit includes pre-operative hospital visits which take place 1 or 2 days prior to surgery, and post-operative care and visits associated with the procedure for up to two weeks post-operatively. (From `:529`)
The surgical benefit does not include the major pre-operative visit, i.e. the consultation or assessment fee which may be claimed when the decision to operate is made and the operation is scheduled, regardless of the time interval between the major pre-operative visit and surgery. (From `:530`)
The listed benefit for a procedure normally includes repair of any iatrogenic complications occurring during the course of the surgery performed by the same surgeon. (From `:530`)
Cosmetic or esthetic surgery is not an insured benefit. Reconstructive surgery to improve appearance and/or function altered by disease, trauma or congenital deformity is insured. (From `:533`)
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