In-Room Procedures

Pre-authorisation is compulsory for in-room procedures and is subject to case management and Scheme protocols. When approved, the procedure(s) will be funded from the Risk benefit.

This procedure list applies to the Platinum, Gold and Silver options.

The Scheme pays for the following procedures at any GP and/or Specialist rooms, provided that the provider has deemed the procedure appropriate and it was approved by the Scheme. The provider will be funded at the following Medical Scheme Tariff (MST):

Platinum – 200% of MST
Gold – 175% of MST
Silver – 150% of MST

GASTROINTESTINAL SCOPES

PROCEDURE CODE	DESCRIPTION
1587	Upper gastro-intestinal endoscopy
1588	Gastro-intestinal endoscopy plus polypectomy
1589	Endoscopic control of gastrointestinal haemorrhage from upper gastrointestinal tract, intestines or large bowel by injection, ligation or application of energy device (endoscopic haemostasis)
1626	Endoscopic examination of the small bowel beyond the duodenojenunal flexure with biopsy, with or without polypectomy, with or without arrest of haemorrhage (enteroscopy)
1653	Total colonoscopy (including biopsy)
1656	Left-sided colonoscopy
1676	Flexible sigmoidoscopy (including rectum and anus)
1677	Sigmoidoscopy with or without biopsy
1678	Polypectomy (with sigmoidoscopy)
1679	Sigmoidoscopy with removal of polyps
1681	Proctoscopy with removal of polyps: First time
1683	Proctoscopy with removal of polyps: Subsequent times

GYNAECOLOGICAL PROCEDURES

PROCEDURE CODE	DESCRIPTION
2295	Marsupialisation (cutting open and stitching the edges) of Bartholin's gland abscess or cyst
2297	Removal of Bartholin gland
2318	Destruction of genital warts, by any method
2319	Removal of vaginal cysts or benign (non-cancerous) tumours
2321	Drainage of vaginal abscess
2395	Colposcopy (examination of the cervix, vagina and vulva using a colposcope) and LLETZ (loop shaped wire used to remove abnormal areas)
2399	Colposcopy (examination of the cervix, vagina and vulva using a colposcope) and biopsy of the cervix
2409	Cervical stitch during pregnancy, vaginal
2429	Colposcopy (examination of the cervix, vagina and vulva using a colposcope)
2436	Examination of the inside of the uterus using a hysteroscope (narrow camera)
2437	Examination of the inside of the uterus using a hysteroscope (narrow camera), taking a sample of the uterus lining and/or removing a polyp with or without a dilation of the cervix and scraping (curettage) (also called D&C) of the uterus.
2443	Dilatation of the cervix and curettage (scraping) of the uterus lining (also called D&C)

ORTHOPAEDIC PROCEDURES

PROCEDURE CODE	DESCRIPTION
0853	Removal of a small bursa or ganglion
0883	Removal of accessible internal fixatives or prosthesis (e.g. plates, screws, nails or wires)
0919	Removal of epidermoid cysts (bumps under the skin)
0920	Removal of ganglion or fibroma

UROLOGY PROCEDURES

PROCEDURE CODE	DESCRIPTION
2015	Suprapubic cystostomy (procedure to help drain the bladder)
2123	Biopsy of penis
2127	Destruction of condylomata/chemo-or cryotherapy: Multiple extensive
2129	Electrodesiccation: Limited number
2131	Electrodesiccation (electric current delivered by a needle-shaped electrode): Multiple extensive
2137	Circumcision, any method
2207	Vasectomy (male sterilisation): Unilateral (one side) or bilateral (both sides)
2215	Incision (cut) and drainage of testis or epididymis e.g. for abscess (swelling caused by pus) or haematoma (swelling caused by blood within tissue)
2217	Excision of local lesion of testis or epididymis
2227	Incision and drainage of scrotal wall abscess

PROCEDURES THAT CAN BE PERFORMED IN ROOMS BY A PLASTIC SURGEON

PROCEDURE CODE	DESCRIPTION
0311	Removal of large benign (non-cancerous) lesion
0314	Repair by large skin graft or large local flap
0315	Repair by small skin graft or small local flap
0319	Incision (cutting) of breast to explore breast tissue, drainage of breast abscess or removal of breast implant
0321	Biopsy or removal of breast cyst, non-cancerous breast lesion, abnormal breast tissue, duct papilloma (wartlike growth in breast ducts)
0853	Removal of small fluid filled sack or ganglion
0883	Removal of internal fixatives or prosthesis
0919	Removal of epidermoid cyst on hand
0920	Removal of ganglion (swelling of a tendon sheath) or fibroma (non-cancerous growth) on hand
1439	Removal of lymph node for biopsy in neck or axilla (armpit)

Please note: Related accounts for in-room procedures, like the anaesthetist, and pathology accounts, will be funded from the Risk benefit at 100% of MST.

Glossary

Colonoscopy	An exam used to look for changes, such as swollen, irritated tissues, polyps or cancer, in the large intestine (colon) and rectum by inserting a long, flexible tube into the rectum.
Gastroscopy/Endoscopy	A procedure where a thin, flexible tube called an endoscope is used to look inside the oesophagus (the gullet), stomach and first part of the small intestine (duodenum), by inserting the tube (endoscope) in the mouth into the stomach.
Haemorrhage	Any bleeding from a damaged or ruptured vessel.
Polypectomy	Removal of a polyp.
Proctoscopy	Procedure to examine the inside of the rectum and anus.
Sigmoidoscopy	Procedure to examine the lower portion of the colon. This procedure can help detect conditions such as colorectal cancer.

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