R416 – Rotator cuff exploration
OHIP Radiology Code — MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
Rotator cuff exploration includes acromioplasty, excision of coraco-acromial ligament and subacromial bursa but excludes simple excision of clavicle. Unit Information: - Assistant Fee (`B` suffix): This service is eligible for an assistant fee calculated based on 6 basic units plus time units. See and for calculation rules. - Anaesthesia Fee (`C` suffix): This service is eligible for an anaesthesia fee calculated based on 10 basic units plus time units. See and for calculation rules. Payment Rules: - When R416 is rendered in association with R298, R416 is payable at 85% and R298 is payable at 100%.
When to Use
- Use R416 when performing a standard subacromial decompression involving acromioplasty, subacromial bursectomy, and coraco-acromial ligament excision.
- Select R416 as the primary procedure when the surgical focus is the subacromial space, rather than a full-thickness rotator cuff repair (which would typically involve R298).
Common Pitfalls
- Do not bill R416 in addition to R298 without applying the 85% reduction to R416, as this is a mandatory payment adjustment rule.
- Avoid billing R416 for a simple distal clavicle excision, as the code description explicitly excludes this procedure.
- Failure to document the specific components (acromioplasty, bursectomy, ligament excision) can lead to audit scrutiny regarding the appropriateness of the R416 fee.
Billing Tips
- When performing both R416 and R298 during the same operative session, ensure the claim reflects the 85% reduction for R416 to prevent automatic rejection or recovery.
- If the procedure is performed after hours, ensure you append the correct E-series premium (e.g., E409 or E410) to the base R416 fee to maximize the procedural reimbursement.
Effective: April 1, 2025
N. Musculoskeletal System Surgical Procedures
MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
Surgical
Musculoskeletal System Surgical Procedures
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