M055 – Caldwell-Luc (includes intranasal antrostomy) - unilateral
OHIP Ophthalmology Code — RESPIRATORY SURGICAL PROCEDURES · Schedule of Benefits
M055A is a unilateral surgical procedure known as the Caldwell-Luc operation. It involves creating an opening into the maxillary sinus through the fossa canina in the upper jaw. The procedure fee also includes the creation of an intranasal antrostomy, which is an opening from the sinus into the nasal cavity to improve drainage. As a surgical service, the fee for `M055A` includes all associated pre-operative and post-operative care as outlined in the Surgical Preamble (). This includes: - Pre-operative hospital visits one or two days before surgery. - Post-operative care and visits for up to two weeks, except for the first two post-operative visits and the discharge day visit by the MRP. - The major pre-operative visit (consultation or assessment where the decision to operate is made) is claimable separately. - Repair of any iatrogenic complications occurring during the surgery.
When to Use
- Use M055A for open surgical access to the maxillary sinus via the canine fossa, specifically when an intranasal antrostomy is performed as part of the same procedure.
- Choose M055A over M054 when the clinical requirement necessitates an external approach (Caldwell-Luc) rather than an endoscopic or endonasal approach.
Common Pitfalls
- Billing M054 in addition to M055A is a common error; the intranasal antrostomy is explicitly included in the M055A fee and cannot be claimed separately.
- Failing to account for the 14-day post-operative period defined in the Surgical Preamble, which renders subsequent related visits non-claimable as they are included in the M055A global fee.
Billing Tips
- Ensure the major pre-operative consultation or assessment is billed separately from M055A, as the surgical fee only covers pre-operative care starting one or two days before the procedure.
- If performing bilateral procedures, bill the first side at 100% and the second side at 85% of the M055A fee, ensuring both are submitted under the same claim.
Effective: April 1, 2025
P. Respiratory Surgical Procedures
RESPIRATORY SURGICAL PROCEDURES
Surgical
Respiratory Surgical Procedures
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