R788 – Ligation of internal maxillary artery - unilateral
OHIP Radiology Code — RESPIRATORY SURGICAL PROCEDURES · Schedule of Benefits
R788 is a surgical procedure categorized under the Respiratory System. The fee includes pre-operative care for 1-2 days before surgery and post-operative care for up to two weeks, with some exceptions for specific visits. This procedure is eligible for the `E676 premium when performed on a morbidly obese patient, which increases the surgeon's fee by 25% and adds 6 basic units for the assistant. After-hours premiums (E409/E410), age-based premiums, and the trauma premium (E420`) may also apply if their respective criteria are met.
When to Use
- Use R788 for the surgical ligation of the internal maxillary artery when performed as a primary procedure to control severe, refractory epistaxis.
- Use R788 when the procedure is performed unilaterally; if bilateral ligation is required, bill R788 with the appropriate bilateral indicator or secondary procedure reduction rules.
Common Pitfalls
- Attempting to bill a hospital assessment or consultation code on the same day as R788 is a common rejection, as the surgical fee includes the major pre-operative visit.
- Failure to document the specific BMI in the medical record when claiming the E676A premium will lead to automatic recovery during an audit.
- Claiming the E420 trauma premium without explicitly documenting the Injury Severity Score (ISS) in the patient's chart is a frequent cause of claim denial.
Billing Tips
- Ensure the E676A premium is only applied if the surgery is performed under general anesthesia using an open technique, as laparoscopic or endoscopic approaches are excluded.
- When performing multiple procedures during the same operative session, ensure the major procedure is billed at 100% and secondary procedures are reduced to 85% per the Schedule of Benefits rules.
Effective: April 1, 2025
P. Respiratory Surgical Procedures
RESPIRATORY SURGICAL PROCEDURES
Surgical
Digestive System Surgical Procedures
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