S036 – Uvulopalatopharyngoplasty (includes tonsillectomy)
OHIP Urology Code — DIGESTIVE SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
Uvulopalatopharyngoplasty is a surgical procedure for the treatment of obstructive sleep apnea. The procedure includes a tonsillectomy. This service is insured only for the treatment of obstructive sleep apnea that is unresponsive to, or intolerant of, continuous positive airway pressure (CPAP), and where the procedure corrects an identified site of airway obstruction causing the apnea. Assistant basic units are 6. Anaesthesia basic units are 6. For details on how assistant and anaesthesia fees are calculated, refer to the Surgical Assistants' Services () and Anaesthesiologists' Services () sections of the General Preamble.
When to Use
- Use S036 when performing a uvulopalatopharyngoplasty specifically for obstructive sleep apnea (OSA) in patients who have failed or are intolerant to CPAP therapy.
- Use this code when the surgical plan explicitly targets an identified anatomical site of airway obstruction that is the documented cause of the patient's OSA.
Common Pitfalls
- Billing S036 for primary snoring or cosmetic pharyngeal surgery will result in rejection, as it is strictly insured only for documented OSA.
- Failing to document the specific CPAP failure or intolerance in the operative note or patient chart is a frequent audit trigger for this code.
- Attempting to bill a separate tonsillectomy code (e.g., S067 or S068) alongside S036 is a billing error, as the tonsillectomy is already included in the S036 fee.
Billing Tips
- Ensure the operative report clearly details the anatomical site of obstruction and the specific clinical evidence of CPAP failure to satisfy the mandatory documentation requirements for S036.
Effective: April 1, 2025
S. Digestive System Surgical Procedures
DIGESTIVE SYSTEM SURGICAL PROCEDURES
Surgical
Digestive System Surgical Procedures
The medical record must document the diagnosis of obstructive sleep apnea, that the patient's condition is unresponsive to or the patient is intolerant of continuous positive airway pressure (CPAP), and the identified site of airway obstruction that the procedure is intended to correct.
As per , the medical record must establish that the service was medically necessary.
Note: S036 Uvulopalatopharyngoplasty is an insured service only under the following conditions: - For the treatment of obstructive sleep apnea that is unresponsive to continuous positive airway pressure (CPAP) or intolerant of continuous positive airway pressure (CPAP) and; - the procedure is rendered to correct an identified site of airway obstruction causing the obstructive sleep apnea.
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