R035 – Pilonidal cyst - simple excision or marsupialization
OHIP Radiology Code — INTEGUMENTARY SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
R035 is a fee code for a surgical procedure, likely within the Musculoskeletal System section of the Schedule. Specific details for this code are not available in the provided context. Payment for this service is subject to the general rules for surgical procedures outlined in the OHIP Schedule of Benefits General Preamble. This includes rules for calculating fees for the surgeon (suffix A) and anaesthesiologist (suffix C). The assistant's service (suffix B) is not payable for this code. The fee for anaesthesia is calculated based on a base unit value and time units. After-hours and age-based premiums may apply.
When to Use
- Use R035 for the surgical excision or marsupialization of a pilonidal cyst when the procedure is performed as a distinct surgical event.
- Select R035 over R054 (Incision and drainage of abscess) when the clinical intent is the definitive removal or marsupialization of the cyst rather than simple drainage.
Common Pitfalls
- Billing R035 in conjunction with an assistant fee (suffix B) will result in an automatic rejection, as the Schedule of Benefits explicitly excludes assistant services for this code.
- Attempting to bill R035 alongside R054 for the same site on the same day is generally considered unbundling; ensure the documentation supports the specific surgical procedure performed.
Billing Tips
- If the procedure is performed in an after-hours setting (e.g., non-elective surgery at night), ensure you append the appropriate premium code (E410) to the procedural fee to maximize reimbursement.
- Always verify the patient's age at the time of the procedure, as age-based premiums (e.g., AGE_PREMIUM_UNDER_16_YEARS) are automatically applicable to R035 and should be claimed if the patient qualifies.
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