R654 – Pericranial flap to orbit or face - unilateral
OHIP Radiology Code — MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
This service is for the unilateral creation and transposition of a pericranial flap to the orbit or face. The pericranium is the membrane covering the outer surface of the skull. - Surgical Fee (`A` Suffix): Flat fee as listed in the Schedule. - Assistant Fee (`B` Suffix): This service does not have a listed assistant basic unit value. As per the rules on , to claim for an assistant, the service must be submitted as M400B and requires authorization by a medical consultant with a letter of explanation from the surgeon. The basic units for this claim are then derived from the anaesthesia value (6 basic units) plus time units as per -. - Anaesthesia Fee (`C` Suffix): Calculated using 6 basic units plus time units as defined in . - Add-on: If this procedure is performed in conjunction with a coronal approach for the main operation, add E973. () - Bilateral Procedure: The bilateral equivalent of this procedure is billed using R655. This service is also eligible for various premiums, including age-based premiums for patients under 16 (), after-hours premiums for non-elective surgery (, , ), and the trauma premium (E420) if applicable criteria are met ().
When to Use
- Use R654 for the unilateral elevation and transposition of a pericranial flap specifically for reconstruction of defects in the orbit or facial region.
- Use R654 when the procedure is performed as a standalone flap transposition; if the procedure is bilateral, you must use R655 instead.
Common Pitfalls
- Attempting to bill an assistant fee directly for R654 will result in rejection, as there is no listed assistant unit value; you must use M400B with a letter of justification.
- Failing to include the E973 add-on code when the procedure is performed via a coronal approach, which is a common oversight in complex craniofacial reconstructions.
- Submitting the trauma premium E420 without explicitly documenting the required Injury Severity Score (ISS > 15 for adults or > 12 for pediatrics) in the patient record.
Billing Tips
- When claiming for an assistant via M400B, ensure the claim reflects 6 basic units to align with the anaesthesia fee structure for R654.
- Always verify if the patient qualifies for age-based premiums (GP64) as these are percentage-based increases that apply directly to the R654 surgical fee.
Effective: April 1, 2025
N. Musculoskeletal System Surgical Procedures
MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
Surgical
Musculoskeletal System Surgical Procedures
For surgical assistant services, where no basic unit is listed for the assistant, payment requires authorization by a medical consultant following submission of a letter from the surgeon outlining the reason the assistant was required. The claim must be submitted using fee code M400B.
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