R549 – Ganglion - simple or complex
OHIP Radiology Code — MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
Represents a surgical procedure on the hemic or lymphatic system. The service is subject to the general rules and definitions outlined in the to of the General Preamble. This includes the common elements of all insured services (-) and specific elements for surgical services. The service is eligible for billing with suffixes <suffix>A</suffix> (surgeon), <suffix>B</suffix> (assistant), and <suffix>C</suffix> (anaesthetist). This procedure may be eligible for age-based premiums (), after-hours procedure premiums for non-elective services (, , ), and the trauma premium (E420) under specific conditions (). The anaesthesia component may be eligible for extra units based on patient status and procedural complexity ().
When to Use
- Use R549 for the surgical excision of a symptomatic ganglion cyst, whether simple or complex, located on the musculoskeletal system.
- Use this code when the procedure involves the formal surgical excision of the cyst, distinguishing it from simple aspiration or injection procedures which are billed under different codes.
Common Pitfalls
- Billing R549 alongside skin flap or graft services is prohibited; these are explicitly restricted from same-day billing per the Schedule of Benefits.
- Failure to document the specific complexity or anatomical location can lead to audit scrutiny if the claim is flagged for review against the 'simple or complex' descriptor.
- Attempting to bill R549 for a simple aspiration; R549 is strictly for surgical excision, not minor office-based drainage.
Billing Tips
- If the procedure requires a skin graft or is a revision surgery, ensure you append the add-on code E831 to receive the 30% fee increase.
- Always verify if the patient meets the criteria for age-based premiums (GP64) or trauma premiums (E420) to maximize the claim value, ensuring the Injury Severity Score is explicitly documented for E420.
Effective: April 1, 2026
N. Musculoskeletal System Surgical Procedures
MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
Surgical
Haematic and Lymphatic Surgical Procedures
All insured services must be documented in appropriate records. The Act requires that the record establish that: 1. an insured service was provided; 2. the service for which the account is submitted is the service that was rendered; and 3. the service was medically necessary.
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