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R119
R119 – Breast mound creation by prosthesis as sole procedure
OHIP Radiology Code — INTEGUMENTARY SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
Breast mound creation by prosthesis as sole procedure. This service is a component of post-mastectomy breast reconstruction. It is listed with 6 base units for an assistant and 7 base units for anaesthesia on page .
When to Use
- Use R119 for the straightforward insertion of a breast prosthesis as the sole procedure in a post-mastectomy patient when no other reconstructive steps like tissue expansion or skin flap reconstruction are performed.
- Select R119 when the clinical intent is exclusively the creation of the breast mound via a standalone prosthetic implant, distinguishing it from R156 which specifically covers the insertion of a tissue expander.
Common Pitfalls
- Billing R119 concurrently with R118 (Breast skin reconstruction) or R156 (Tissue expander insertion) will trigger an automatic rejection, as R119 is strictly defined as a sole procedure.
- Attempting to bill add-on codes E529 or E513 alongside R119 is prohibited by the Schedule of Benefits, as these are restricted in the context of this specific breast mound creation code.
Billing Tips
- Ensure the operative note explicitly states that the procedure was limited to the creation of the breast mound by prosthesis to justify the 'sole procedure' designation and avoid audit scrutiny regarding unbundling.
- If the procedure is performed after hours or involves a pediatric patient, apply the appropriate age-based or after-hours premiums (E409/E410) to the base fee, as these are permitted and do not violate the 'sole procedure' restriction.
Provider Fee$350.00
Surgical Assistant Fee$75.06
Anaesthetist Fee$108.43
Non-Anaesthetist Fee$108.43
Effective: April 1, 2025
Category
M. Integumentary System Surgical Procedures
Subcategory
INTEGUMENTARY SYSTEM SURGICAL PROCEDURES
Service Type
Surgical
Code Classes
Integumentary System Surgical Procedures
All insured services must be documented in appropriate medical records, establishing that the service was provided, medically necessary, and is the same as the service submitted for payment.
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