R048 – Simple excision of single malignant lesion - face or neck
OHIP Radiology Code — INTEGUMENTARY SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
This service covers the simple excision of a single malignant lesion, including the biopsy, when located on the face or neck. The amount payable will be adjusted to a lesser fee if the pathologist's report is not retained in the patient's record. This code is not applicable for pre-malignant lesions. When the surgical defect is repaired using advanced techniques like flaps or grafts, the appropriate repair code from the Repair Section should be claimed instead of R048. For billing anaesthesia or surgical assistant services, the base units are 6 for anaesthesia (<suffix>C</suffix>) and 6 for assistant (<suffix>B</suffix>).
When to Use
- Use R048 for the simple excision of a single biopsy-proven malignant lesion on the face or neck that is closed primarily with sutures.
- Use R048 when performing an excision of a malignant lesion where the closure does not involve complex techniques like Z-plasty, flaps, or grafts.
Common Pitfalls
- Claiming R048 for pre-malignant lesions, such as actinic keratosis, which are ineligible for this code and should be billed under benign lesion codes like R040.
- Failing to retain the pathology report in the patient record, which triggers an automatic audit adjustment to a lower fee.
- Billing R048 alongside a repair code from the Repair Section; if a flap or graft is used to close the defect, you must bill the repair code instead of R048.
Billing Tips
- If you excise two malignant lesions on the face or neck on the same day, you must bill R049 instead of two units of R048.
- Document the specific S-plasty technique if used, as this is considered a simple excision and remains eligible for R048 rather than requiring a higher-tier repair code.
Effective: April 1, 2026
M. Integumentary System Surgical Procedures
INTEGUMENTARY SYSTEM SURGICAL PROCEDURES
Surgical
Integumentary System Surgical Procedures
The pathologist's report must be retained in the patient's record.
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