Peripheral nerve surgical procedures (N291, N293)
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: Plastic Surgery; Orthopaedic Surgery; Neurosurgery; Anaesthesia; Surgical Assistants
Date Issued: February 15, 2024
Claims Tip: Fee codes for major and minor peripheral nerve transfers have been introduced to the Schedule of Benefits – Physicians Services (Schedule) as of April 1, 2023.
Nerve Transfers (N293; N291)
New fee codes have been introduced to the Schedule for payment of nerve transfer procedures, including:
- N291 – Major nerve transfer – mixed sensory and motor nerve or pure motor nerve
- N293 – Minor nerve transfer – sensory/cutaneous nerve
These two new fee codes are for payment of coaptation of one or more donor nerve fascicles to a recipient nerve.
The services described by the two new nerve transfer fee codes (N291 and N293) include:
- All related nerve exploration, decompression, division, excision and/or neurolysis of the involved donor and recipient nerves.
- Suturing/coaptation of the donor fascicle(s) to the recipient nerve.
- Guidance, nerve stimulation or nerve mapping, if performed.
Note that if any branches transected during harvest of the donor nerve are repaired during the same procedure, this repair is a component of the nerve transfer and should not be claimed separately.
Anastomosis of the hypoglossal or accessory nerve to the facial nerve is specifically listed in the Cranial section of the Schedule. N265 is to be used when billing this procedure. N291 and N293 are not eligible for payment for this procedure.
Applicable premiums
- E906 is payable for nerve transfers when performed using the operative microscope.
- E925 is payable for repeat peripheral nerve transfers or when an acute nerve injury is repaired by means of a nerve transfer performed more than 4 weeks following the original nerve injury.
Submitting claims for nerve transfer procedures involving two surgeons
- No team fees are payable for nerve transfer procedures.
- When two surgeons are working together to perform multiple nerve transfers, one surgeon should identify themselves as the operating surgeon and submit claim(s) for payment accordingly. The second surgeon should submit claim(s) for payment as surgical assistant.
- If both surgeons submit operating surgeon fee codes, only the first claim received by the ministry is eligible for payment.
Other changes to the Peripheral Nerves section of the Schedule
The Peripheral Nerves subsection (found in the Neurological Surgical Procedures section of the Schedule) has been revised with the following changes:
- E906 (operating microscope premium) now specifically lists the applicable procedures, including the new nerve transfer procedure.
- E925 has been revised to clarify that it is payable in one of 2 circumstances:
- when a repeat N-prefix procedure from the Peripheral Nerve section of the Schedule is performed, or
- when repair of an acute nerve injury is performed by nerve suture, transfer or graft more than 4 weeks following the original nerve injury.
- Note that E925 is not payable for treatment of chronic nerve conditions such as carpal tunnel syndrome unless the procedure is a repeat procedure.
- Peripheral nerve fee codes listed in other parts of the Schedule have been consolidated in the Peripheral nerve section under the heading “Exploration, decompression, division, excision, biopsy, neurolysis and/or transposition” (i.e., all of these fee codes include exploration, decompression, division, excision, biopsy, neurolysis and/or transposition if performed), including:
- N188 – minor nerve – including digital, cutaneous or lateral femoral cutaneous nerve
- N285 – major nerve – excluding carpal tunnel or ulnar nerve at elbow
- N283 – Decompression, exploration for thoracic outlet syndrome including excision of cervical and/or first rib and to include scalenectomy
- N282 – Brachial plexus (excluding thoracic outlet syndrome or cervical rib)
- N290 – Carpal tunnel release
- N190 – Exploration and/or decompression and/or neurolysis of ulnar nerve (elbow)
- N189 – Ulnar nerve transposition at elbow – may include exploration, decompression and/or neurolysis
- N177 – Sciatic nerve in buttock
- N184 – Decompression of posterior tibial or common peroneal nerve
- N286 – Tumour or neuroma – major nerve
- N295 – Excision of Morton’s or subcutaneous neuroma, glomus or small cutaneous nerve tumour
- E911 – implantation of neuroma into bone or muscle, add to N286 or N295
- Note that when nerve exploration, decompression, and/or neurolysis is done as part of surgical exposure for another procedure, it is considered part of the main operative procedure and therefore should not be claimed separately.
Examples
Example 1:
Dr. Fanella, a plastic surgeon, performs the following surgical procedures to treat a patient with chronic right ulnar neuropathy:
- Decompression and transposition of the ulnar nerve at the elbow.
- Transfer of the anterior interosseous nerve to the distal ulnar nerve at the wrist (including decompression of Guyon’s canal) using the operating microscope.
What is eligible for payment to Dr. Fanella? Are E906 and E925 payable?
Explanation:
- Decompression and transposition of the ulnar nerve at the elbow is eligible for payment as N189. This includes any necessary exploration, decompression and/or neurolysis as well as any soft tissue procedures required to maintain the nerve in the transposed position.
- Transfer of the anterior interosseous nerve (AIN) to the distal ulnar nerve is a major nerve transfer that is eligible for payment as N291. This includes any exploration, decompression or neurolysis of both nerves such as release of Guyon’s canal as well as coaptation/suture of the fascicles of the AIN to the ulnar nerve.
- E906 is eligible for payment in addition to N291 as the operating microscope was used. Note that this premium is not payable for the use of other types of magnification such as loupes.
- As this is not a repeat procedure or delayed repair of an acute nerve injury, E925 is not eligible for payment.
Example 2:
Dr. Fanella and Dr. Ortiz (also a plastic surgeon) work together to perform 3 major and 2 minor nerve transfers for a patient with a complex extremity injury sustained less than 4 weeks previously.
Dr. Fanella performs 3 transfers and Dr. Ortiz performs 2 transfers.
The nerve transfers are performed using the operative microscope. The surgical procedure start time is 08:00 am and stop time 12:30 pm (4.5 hours). Both surgeons are present for the entire operation.
What fee codes are eligible for payment to Dr. Fanella and Dr. Ortiz?
Explanation:
There is no provision in the Schedule to allow two surgeons to be paid surgical fees as the operating surgeon in this circumstance as both surgeons are performing similar operations and share the same training.
- As only one surgeon is eligible for payment as the operating surgeon, Dr. Fanella and Dr. Ortiz should decide who will submit claims for payment for all surgical procedures performed by both surgeons – in this case N291A x 3 and N293A x 2.
- In this example, the physicians decide that Dr. Fanella will submit all surgical procedure claims.
- As the repairs were done using the operating microscope, E906A is eligible for payment to Dr. Fanella.
- E925A is not eligible for payment because the injury was sustained less than 4 weeks from the date of the surgical procedure.
- Dr. Ortiz may submit claims as the surgical assistant – in this case N293B x 46 (6 basic units and 40 time units) is eligible for payment.
Example 3:
Dr. Keats, an orthopaedic surgeon, performs open reduction of a congenitally dislocated hip in a child using an anterior surgical approach. This includes identification, neurolysis and protection of the lateral femoral cutaneous nerve as well as iliopsoas tenotomy.
What is eligible for payment to Dr. Keats? Is N188A payable?
Explanation:
- R406A is eligible for payment to Dr. Keats for open reduction of the congenital hip dislocation which includes arthrotomy and psoas tenotomy.
- Identification, neurolysis and protection of the lateral femoral cutaneous nerve is considered part of this procedure and of any anterior surgical approach to the hip for payment purposes and is included in R406A. Therefore, N188A is not eligible for payment.
Keywords/Tags
Peripheral nerve; nerve transfer; nerve graft; OHIP Claims; OHIP Payment
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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.
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
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