R460 – Tibial stapling - both sides
OHIP Radiology Code — MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
This code represents a surgical procedure. The specific details of this procedure are not provided in the context. However, all surgical services include common elements as described in and . For the Surgeon (Suffix A): The fee for the surgeon typically includes the major pre-operative visit and post-operative care for a specified period, as defined in the surgical preambles. The specific elements of surgical procedures are not detailed in the General Preamble but are generally understood to include the operation itself and related pre- and post-operative care. For the Surgical Assistant (Suffix B): The service includes specific elements as defined in : - Preparing or supervising the preparation of the patient. - Assisting in the performance of the procedure, recovery room procedures, and patient transfer. - Making arrangements for related assessments or therapy. - Post-procedure monitoring until the first post-operative visit. - Discussion and advice to the patient or representative. For the Anaesthesiologist (Suffix C): The service includes specific elements as defined in : - A pre-anaesthetic evaluation. - The anaesthetic procedure and supportive measures. - Post-anaesthetic follow-up, including recovery room procedures and monitoring. - Making arrangements for related care. - Discussion and advice to the patient or representative.
When to Use
- Use R460 specifically for bilateral tibial stapling procedures where both limbs are addressed in the same operative session.
- Choose R460 over unilateral codes when the surgical intent and documentation confirm bilateral application of staples for growth modulation or fixation.
Common Pitfalls
- Billing R460 in conjunction with other musculoskeletal surgical codes for the same site may trigger a 'multiple procedure' audit if the services are considered inclusive.
- Failure to document the specific indication for bilateral stapling can lead to rejection if the claim is flagged for review against the global surgical period.
Billing Tips
- Ensure that if a surgical assistant is utilized, their claim is submitted with the 'B' suffix to correctly trigger the assistant fee structure associated with this musculoskeletal procedure.
- If the procedure is performed after hours or in an emergency, ensure the appropriate E-code premium is applied to the surgeon's fee to reflect the non-elective nature of the service.
Effective: April 1, 2025
N. Musculoskeletal System Surgical Procedures
MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
Surgical
Urogenital and Urinary Surgical Procedures
Cancelled Surgery (Assistant): If the anaesthetic has begun but the operation is cancelled prior to commencement of surgery and the assistant has scrubbed but is not required to do anything further, the service is payable as E006B with 6 basic units plus time units. If the operation is cancelled after surgery has commenced, the amount payable is calculated by adding the listed procedural basic units plus time units.
Cancelled Surgery (Anaesthetist): If an anaesthesiologist examines a patient prior to surgery and the surgery is cancelled prior to the induction of anaesthesia, the service rendered constitutes a hospital subsequent visit. When an anaesthetic has begun but the operation is cancelled prior to commencement of surgery, the service constitutes E006C with 6 basic units plus time units.
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