Education and Prevention Committee Billing Briefs

Education and Prevention Committee (EPC) Billing Briefs are prepared jointly by the Ministry of Health (MOH) and the Ontario Medical Association (OMA) to provide general advice and guidance to physicians on billing matters.

Category: General Surgery; Plastic Surgery; Anaesthesia; Surgical Assistants
Date of publication: April 24, 2024

Claims Tip: Fee codes for oncoplastic breast conserving surgery performed by a single surgeon have been introduced to the Schedule of Benefits – Physician Services (Schedule) as of April 1, 2023.

Oncoplastic Breast Surgery (R102, R158, R159)

Oncoplastic breast surgery combines the techniques of traditional breast cancer surgery with the cosmetic advantages of plastic surgery to remove cancer while minimizing the unwanted effects of surgery.

The new fee codes (R102, R158 and R159), introduced to the Schedule as of April 1, 2023, represent 3 levels of volume-displacement techniques separated according to the complexity and level of skill and training required for each.

Note that these fee codes are for sole physician procedures and can only be used in the setting of a malignant tumour requiring resection.

 

R102 – Oncoplastic Breast conserving lumpectomy or partial mastectomy for malignancy (Level 1)

For R102 to be eligible for payment:

  • Resected breast volume must be less than or equal to 15% (of total breast volume on same side), AND,
  • The operative report must document dual plane undermining and lumpectomy defect closure.

Note that nipple undermining, nipple-areolar complex elevation/centralization, skin resection and glandular advancement are all considered components of R102, if performed.

R102 is not eligible for payment if:

  • Additional ipsilateral breast reconstructive procedure(s) are performed on the same day by a second surgeon, or,
  • The procedure is part of a pre-planned staged breast reconstruction.

Note that R143 (contralateral balancing mastopexy or reduction) is not eligible for payment on the same day as R102.

R158 – Oncoplastic Breast conserving lumpectomy or partial mastectomy for malignancy (Level 2)

For R158 to be eligible for payment:

  • Resected breast volume must exceed 15%, OR,
  • Tumour is resected from the upper inner quadrant, or the lower pole of the breast, AND,
  • The operative report must document:
    • purposeful skin excision,
    • glandular rotations,
    • pre-emptive nipple recentralization, and,
    • de-epithelialization techniques that preserve blood supply to the nipple-areolar complex and parenchyma.

R158 is not eligible for payment if:

  • Additional ipsilateral breast reconstructive procedure(s) are performed on the same day by a second surgeon, or,
  • The procedure is part of a pre-planned staged breast reconstruction.

R159 – Oncoplastic Breast conserving lumpectomy or partial mastectomy for malignancy (Level 3)

For R159 to be eligible for payment:

  • Resected breast volume must exceed 25%, AND,
  • The operative report must document ipsilateral reduction mammoplasty techniques sufficient to achieve cosmesis.

Note that glandular pedicles coupled with large mobilizations, transpositions and rotations of residual breast tissue are all considered components of R159, if performed.

R159 is not eligible for payment if:

  • Additional ipsilateral breast reconstructive procedure(s) are performed on the same day by a second surgeon, or,
  • The procedure is part of a pre-planned staged breast reconstruction.

Examples

Example 1

Dr. Powell, a general surgeon, treats a patient with extensive, symptomatic, non-cancerous breast disease. Given his previous advanced training in oncoplastic surgery, Dr. Powell advises the patient that resection of the tumour and cosmetic closure can be performed in one surgery. Dr. Powell performs a wedge resection in the upper, outer quadrant of the right breast, removing approximately 10% of the breast volume. Cosmesis was maintained using dual plane undermining.

What is eligible for payment to Dr. Powell for this procedure?

Explanation:

  • R111 (Partial mastectomy or wedge resection for treatment of breast disease, with or without biopsy, example, carcinoma or extensive fibrocystic disease) is eligible for payment.
  • Even though cosmetic breast conserving techniques were used, R102 is only eligible for payment when a malignant breast tumour is excised, which is not the case in this example.

Example 2

A 55-year-old woman has a small mass discovered in the lower pole of her right breast on a screening mammogram. A needle biopsy confirms this to be ductal carcinoma. Dr. Guzman performs and documents in the operative report an oncoplastic resection/reconstruction with purposeful skin excision, glandular rotations, pre-emptive nipple recentralization, and de-epithelialization techniques that preserve the blood supply to the nipple-areolar complex and parenchyma. The resection resulted in a 10% volume loss of the right breast.

What is eligible for payment to Dr. Guzman for this procedure?

Explanation:

  • R158 is eligible for payment for the described procedure.
  • R158 is applicable because:
    • the breast cancer was in a cosmetically sensitive location, namely the lower pole of the breast, and,
    • the surgical techniques used meet the requirements for R158, and,
    • documentation is included in the operative report.
  • In any location other than the upper inner quadrant or the lower pole of the breast, the volume of breast resected would have to exceed 15% for R158 to be eligible for payment.

Example 3:

When removing a left breast cancer, Dr. Barajas clearly describes purposeful skin excision, glandular rotations, pre-emptive nipple recentralization and de-epithelialization techniques that preserve blood supply to the nipple-areolar complex and parenchyma in the operative report. Resection resulted in a 30% volume loss to of the left breast.

What is eligible for payment to Dr. Barajas for this procedure?

Explanation:

  • R158 is eligible for payment for the described procedure.
  • R158 is eligible because:
    • resected breast volume was greater than 15%, and,
    • the surgical techniques used meet the requirements for R158, and,
    • documentation is included in the operative report.
  • Despite excising more than 25% of breast tissue, no reduction mammoplasty techniques were used. Therefore, R159 is not eligible for payment.

Example 4

Dr. Chan, a general surgeon, performs a left-sided lumpectomy for breast cancer, removing approximately 30% of the patient’s left breast tissue. Dr. Aziz, a plastic surgeon, performs immediate left breast reconstruction with implantation of a submuscular prosthesis and extensive skin reconstruction involving flaps and nipple-areola-complex reconstruction as well as a balancing right breast reduction.

What should Dr. Chan and Dr. Aziz bill for this procedure? Are oncoplastic fee codes applicable?

Explanation

  • R111 is eligible for payment to Dr. Chan for the lumpectomy.
  • Fee codes eligible for payment to Dr. Aziz include the following:
    • R156 for insertion of the prosthesis,
    • R118 for the extensive skin reconstruction,
    • E514 indicating that these procedures were performed at the same time as the mastectomy, and,
    • R143 for the right breast reduction.
  • Oncoplastic breast surgery fee codes (R102, R158 or R159) are not eligible for payment to either physician as these fee codes are not payable when:
    • additional ipsilateral breast reconstructive procedure(s) are performed on the same day by a second surgeon, or,
    • the procedure is part of a pre-planned staged breast reconstruction.
  • Oncoplastic breast surgery fee codes are only applicable for sole surgeon procedures.

Example 5

Dr. Rodgers, a general surgeon, excises a right breast tumour using oncoplastic reduction mammoplasty techniques and having met the payment requirements, correctly claims fee code R159. During the same surgery, a plastic surgeon, Dr. Turcke, performs a left breast balancing reduction mammoplasty.

What is eligible for payment to Dr. Turcke?

Explanation

  • R143 is eligible for payment to Dr. Turcke for left balancing mastopexy or reduction.
  • R159 is not payable to Dr. Turcke for the left breast procedure because this fee code requires the excision of a breast cancer in the same breast to meet payment requirements. In this example, the breast cancer excised was in the right breast and by a different physician.

Keywords/tags

OHIP; lumpectomy; mastectomy; oncoplastic; breast surgery; malignancy; reconstruction

Contact information

For additional information, please visit the Resources for Physicians and the How to Get Help with Billing Questions pages on the ministry website.

If you have any billing or claims submission inquiries, please contact the Inquiry Services, Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

To provide feedback on EPC Billing Briefs, or to suggest topics for future EPC Billing Briefs, send an email to the attention of the joint MOH/OMA Education and Prevention Committee.

The Ministry of Health (MOH) and the Ontario Medical Association (OMA) have jointly prepared this educational resource to provide general advice and guidance to physicians on specific billing matters.

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Note: This document is technical in nature and is available in English only due to its limited targeted audience. This publication has been exempted from translation under the French Language Services Act. For questions or support regarding this document, please contact the Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

Remarque : Ce document est de nature technique et est disponible en anglais uniquement en raison de son public cible limité. Ce document a été exempté de la traduction en vertu de la Loi sur les services en français. Pour toute question ou de l’aide concernant ce document, veuillez contacter Les Services de renseignements, Centre de contact pour le soutien des services par courriel ou en téléphonant le 1-800-262-6524.