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Important Information

Simple lower back pain procedures

In line with the NICE clinical guideline 88 'Low back pain: early management of persistent non-specific low back pain' we:

  • don't cover X-rays of the lumbar spine for the management of non-specific low back pain
  • only offer cover for an MRI (magnetic resonance imaging) scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion
  • will only cover one spinal injection of therapeutic substances into the back for non-specific low back pain if being carried out for diagnostic purposes
  • don't cover any of the following procedures for non-specific low back pain:
    • intradiscal electrothermal therapy (IDET)
    • percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)
    • radiofrequency facet joint denervation

Unlisted Procedures

If a procedure is planned for which there is no code in this schedule, please contact the telephone number below with details or apply to www.ccsd.org.uk for a new code. Unproven or experimental procedures are excluded from cover under Cigna's Healthcare Plans.

Bilateral and Multiple Procedures

The majority of all common clinical interventions should have a single CCSD code. This code fully describes the procedure from start to finish. The code covers the actual operation itself and all component parts and additional procedures, which are routinely or commonly performed with the operation.

For example:

  • Pre-operative assessment
  • Anaesthesia
  • Intra-operative care
  • Post-operative care
  • Intensive care
  • Wound dressing and care
  • Analgesia

Common bilateral procedures are listed in the schedule and have their own code and description and maximum fees. For non-listed bilateral and for multiple procedures performed under the same anaesthetic, the following formula should be used to calculate the maximum allowed for both the surgeon and anaesthetist.

  • When two procedures are carried out at one operation the maximum benefit available is 125% of the most complex procedure.
  • In the unlikely event that three (or more) procedures are carried out at one operation the maximum benefit payable is 140% of the most complex procedure.

When procedures are performed incidentally at the same time as other procedures, no supplement will be payable. Where a single procedure involves lesser procedures listed in the schedule in their own right, it should not be separated into its component parts, this is considered as unbundling.

These codes (A5210, S5210, W9040 and A7350) are not allowed as additional codes for extra benefit, either at point of pre-authorisation and at claims payment; the fee for pain relief is included in the main CCSD code.

Stand by Fees

Stand by fees will only be paid if it is clinically necessary to have a stand by surgeon and / or anaesthetist and the specialists concerned are physically present at the procedure. Details should be submitted to Cigna's Provider Affairs Department for consideration prior to the procedure being carried out.

Second Specialists

If through clinical necessity, a second specialist is required to assist during a procedure, a separate fee may be payable. Details should be submitted to Cigna's Provider Affairs Department for consideration prior to the procedure being carried out. No additional fee is payable for the services of surgical assistants.

Concomitant Disease or Complications Not Directly Related to the Initial Condition

In this event, a supplementary fee may be payable. Details should be submitted to Cigna's Provider Affairs Department for consideration prior to the procedure being carried out.

Fraud and misrepresentation

Cigna Healthcare monitors claims by conducting claims audits and by reference to medical records. We operate a policy of zero tolerance of fraud and misrepresentation and will cease to deal with any provider who provides false, misleading or selective information. Cigna considers the following to constitute fraudulent billing:

  • Exaggeration of the complexity of the procedure performed. E.g. coding a diagnostic procedure as if it were therapeutic procedure
  • Misrepresentation of the medical history or the procedure performed
  • Omission of material facts
  • Unbundling

Coding principles

These coding principles set out how the codes and narratives within the Cigna Fee Schedule are interpreted and used.

The Principles:

  1. Single Codes 'are the norm'

    All CCSD Schedule users should use a single CCSD code to describe the majority of common clinical interventions. This single code fully describes the procedure from start to finish.

    The code covers the actual operation itself and all component parts and additional procedures, which are routinely or commonly performed with the operation. For example:

    • pre-operative assessment
    • anaesthesia
    • intra-operative care
    • post-operative care
    • intensive care
    • wound dressing and care
    • immediate post operative analgesia
  2. Where Two Codes are Used - Generate a New Code Request

    No common clinical intervention should routinely require more than one code but occasionally, two procedures undertaken at the same attendance may legitimately require two codes to fully describe them.

    In the event that there is more than one code to describe a common clinical intervention, then a new code request should be made so that an additional single code may be issued.

  3. Therapeutic and Diagnostic Combinations on the Same Organ
    • Therapeutic procedures are prime procedures and secondary diagnostic procedures on the same organ or approach to that organ would be likely to create an inappropriate combination of codes.
    • Coding more than one diagnostic procedure within the same organ or approach to that organ is likely to create an inappropriate combination of codes.
    • Coding more than one therapeutic procedure within the same organ or approach to that organ is likely to create an inappropriate combination of codes.
  4. Use of Open, Endoscopic and Percutaneous Code Combinations

    If a procedure code narrative does not specify whether it is an open or an endoscopic procedure, then the use of that code with another procedural narrative that does specify it as endoscopic is likely to create an inappropriate combination of codes

    • For example:
      M2930 Removal of prosthesis from ureter
      +
      M3000 Endoscopic examination of ureter

      The combination of an open and an endoscopic procedure to the same organ is likely to create an inappropriate combination of codes.
    • For example:
      M0610 Open removal of calculus from kidney
      +
      M1000 Therapeutic endoscopic operations on kidney (include cystoscopy and retrograde catheterisation)

      The combination of an open and a percutaneous procedure to the same organ is likely to create an inappropriate combination of codes
    • For example:
      M0610 Open removal of calculus from kidney
      +
      M0940 Percutaneous nephrolithotomy (including cystoscopy and retrograde catheterisation)

      A combination of procedure codes to the same organ or approach to that organ is likely to create an inappropriate combination of codes.
      A combination of procedure codes with different approaches (open, endoscopic or percutaneous) to the same organ specified in the narrative is likely to create an inappropriate combination of codes.
      A combination of procedure codes with the same approach (open, endoscopic or percutaneous) to the same organ specified in the narrative is likely to create an inappropriate combination of codes.
    • For example:
      M0610 Open removal of calculus from kidney
      +
      M0800 Other open operations on kidney
  5. Subset Procedures

    A combination of procedure codes that would include a smaller subset code in the main procedure code will create an inappropriate combination of codes.

    • For example:
      N0500 Bilateral excision of testes
      +
      N0700 Excision of lesion of testis

Notes on Interpretation:

  • The principles make reference to an organ or an approach to that organ. This phrase refers to the use of two procedure codes where one represents: access to, facilitation of, or prevention of complications, relative to the second procedure and is therefore considered to be part of the same procedure, e.g. Coding for an internal urethrotomy at the same time as a Trans Urethral Resection of the Prostate
  • For the purpose of interpretation, the term "biopsy" is used in both diagnostic and therapeutic context within the CCSD Schedule.
  • In the event that a patient has two different ICD-10 diagnostic codes assigned to them for the same episode of treatment, it would be acceptable to assign two CCSD codes to describe the different procedures used to treat the two conditions.
  • Principles are equally applicable to both surgeons and anaesthetists in their use of CCSD codes and narratives.

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