Z165 – Congenital nevus (extensive)
OHIP Psychiatric Code — INTEGUMENTARY SYSTEM SURGICAL PROCEDURES · Schedule of Benefits
Excision of an extensive congenital nevus, classified under Group 2 lesions (nevus).
As this service is designated for Independent Consideration (IC), the fee is not specified in the Schedule. Claims must be submitted with a supporting letter explaining the amount of the fee claimed, including an appropriate operative or consultation report, and a comparison of the scope and difficulty of the procedure in relation to non-IC procedures in the Schedule (see ). This applies to the surgeon's fee, as well as the fees for the assistant (Asst) and anaesthetist (Anae).
When to Use
- Use for the surgical excision of a large, congenital nevus that requires complex reconstruction or significant tissue mobilization beyond the scope of standard lesion removals like Z156 or Z157.
- Use when the clinical documentation confirms the procedure is medically necessary due to high risk of malignancy or functional impairment, rather than for cosmetic improvement.
Common Pitfalls
- Submitting the claim without a detailed operative report or a comparative analysis letter will result in automatic rejection or a request for manual review.
- Failing to explicitly justify the fee amount by comparing the complexity to a non-IC procedure (e.g., comparing the tissue transfer difficulty to a specific flap procedure code) is a frequent cause of payment delays.
- Billing Z165 for cosmetic removal of a nevus is an audit risk, as OHIP does not cover procedures performed solely for aesthetic purposes.
Billing Tips
- When drafting your supporting letter, explicitly reference the time, technical difficulty, and specific anatomical challenges to justify the IC fee relative to standard surgical codes.
- Ensure the operative report clearly describes the dimensions and the reconstructive technique used, as this is the primary evidence used by the Ministry to determine the appropriate IC value.
No fee information available.
M. Integumentary System Surgical Procedures
INTEGUMENTARY SYSTEM SURGICAL PROCEDURES
Surgical
Integumentary System Surgical Procedures
Claims must be submitted with a supporting letter explaining the amount of the fee claimed.
Must include an appropriate operative or consultation report.
Must include a comparison of the scope and difficulty of the procedure in relation to non-IC procedures in the Schedule.
The schedule notes to see .
Tattoo removal - (see Appendix D Surface Pathology Section 3).
Removal of any lesions (e.g. keratosis, nevi) for cosmetic purposes and not for any clinical suspicion of disease or malignancy is not an insured service.
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