1105 two (2) vertebrae... 1, add on per additional vertebra

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1 SPINE STAGE OPERATIONS Staged operations shall be paid at 100% for the first stage and 85% for the second stage. Where the second stage pays a higher fee 100% shall be paid and the first stage shall be paid at 85%. ANTERIOR INSTRUMENTATION Cervical C2-C two (2) vertebrae... 1, add on per additional vertebra Cervico-Thoracic C7-T two (2) vertebrae... 1, add on per additional vertebra Dorsal 0645 Anterior Instrumentation of Spine and/or Osteotomy, via chest via abdomen... 1, via chest and abdomen... 1, DECOMPRESSION Cervical-Thoracic-Lumbar 5203 Intervertebral discs, excision anterior approach, cervical... 1, Laminectomy, for decompression of the spinal cord and nerve roots Laminectomy, for lesion of spinal cord or meninges each additional level, add to 5205 and/or Laminotomy, cervical Excision of lumbar intervertebral disc, one (1), all methods, any approach e.g. minimally invasive, includes all associated bone and soft tissue procedures e.g. laminotomy, foraminotomy, laminectomy, facetectomy, fat graft, microscope, fluoroscopy more than one (1)... 1, Vertebrectomy including disc and adjacent end plates, add... 1, per additional vertebra, add Radical total disc excision with end plates, add per additional vertebra, add Partial vertebrectomy, add Posteriolateral decompressions-one side includes lamina, facets, pedicles, add per side or per additional vertebra, add F-6 April 1, 2010

2 FUSION-CERVICAL POSTERIOR FUSION 1116 Occipito-cervical fusion (includes wires, screws and graft when necessary)... 1, add on per vertebra below C C1-C2 fusion wires and graft C1-C2 fusion including transarticular screws and wires... 1, add on flat bone graft CERVICO-THORACIC-LUMBAR 0636 Spine, two (2) vertebrae, (e.g. lumbo-sacral) three (3) to five (5) vertebrae More than five (5) vertebrae... 1, Posterior or Posteriolateral fusion with instrumentation including pedicle screws, two (2) vertebrae... 1, add on per additional vertebra add on per Sacral vertebra (maximum per patient $3,000.00) ALIF OR PLIF Alif-(anteriorlumbar interbody fusion) Plif-(posteriorlumbar interbody fusion) 1124 Vertebra Replacement with autogenous or allograft bone, cement, tri-cortical bone and/or cage per vertebra, add Intervertebral disc replacement any type for radical disc excision tricortical strut graft, autograft, allograft, bone cement prosthetic with or without cage, per vertebra, add Artificial disc insertion each additional level replaced, add KYPHO-SCOLIOSIS Anterior Release includes discectomy and section of longitudinal ligament including open or thoroscopic approach 1128 one (1) intervertebral disc space two (2) three (3) intervertebral disc spaces... 1, four (4) six (6) intervertebral disc spaces... 2, Greater than six (6) intervertebral disc spaces (per disc space) (maximum per patient including fusion $3,000.00), add Fusion with anterior release with morsellized non-structural bone graft per intervertebral disc space, add April 1, 2010 F-7

3 BONE GRAFT Procurement and application of graft from remote site 1133 Onlay graft for posterior lateral fusion, add MISCELLANEOUS 1134 Laminoplasty add on per additional vertebra Odontoidectomy, transoral with microscope... 1, Open Vertebroplasty, posterior approach with augmentation of bone with autograft, bone cement or bone substitute... 1, Odontoid fracture open reduction and interior fixation with screw... 1, Multi-Level saucerization of spinal wound with re-open for infection, drainage of hematoma, including debridement Where required, re-instrumentation may be claimed in addition to Tariff Intra-operative ultrasound monitoring, add MEP/SSEP electro-physiological monitoring, primary spine surgeon, add MEP/SSEP electro-physiological monitoring, non-operating physician per hour or major portion FRACTURES These benefits cannot be correctly interpreted without reference to Rules of Application 34 to 42. In compound fractures requiring closed reduction $47.00 may be added to the fee for closed reduction. HEAD Skull, non operative depressed with operation See Nervous System FACIAL BONES 0686 Nasal, simple, closed reduction with or without nasal packing or splinting compound, closed reduction simple or compound, open reduction Malar, simple, closed reduction simple or compound, depressed, open reduction multiple surgical procedures Maxilla, simple, closed reduction simple or compound, closed reduction with wiring of teeth simple or compound, open reduction with wiring of teeth or local fixation F-8 April 1, 2010

4 Cardiovascular System H CARDIOVASCULAR SYSTEM These benefits cannot be correctly interpreted without reference to the Rules of Application. CODE STEMI ECG INTERPRETATION ~9727 Code STEMI ECG Interpretation ) This tariff may be claimed for the immediate interpretation of an ECG submitted electronically to the physician by a paramedic requesting direction as to appropriate care of a patient with a suspected ST elevated myocardial infarction (STEMI) (e.g., immediate thrombolytic drug treatment and/or percutaneous coronary intervention). 2) No claim may be made until the Physician responds to the request. 3) The tariff includes all related communications with a paramedic and other health care providers, if required, regarding the care and treatment of the patient during the patient s transport to hospital. 4) Claims for additional services rendered to the patient, including subsequent ECG interpretation, may be made in addition to this tariff. 5) The claim must include the name of the paramedic who initiated the request to the physician for ECG interpretation and the time of day the communications were completed. 6) When applicable, after hours premium may be claimed. 7) Services shall be documented in the Patient Care Report (PCR) generated by the paramedic and such documentation is required, upon request by Manitoba Health, to support the claim submitted. HEART AND PERICARDIUM Numbers (1) through (4) are applicable to Manitoba Physicians only. 1) ECGs that are performed for screening or are medically unnecessary are not insured services. 2) Neither Tariff 9836 nor Tariff 9838 will be paid unless: The tracing is interpreted within a period of 30 days from the time the tracing was taken, and The interpretation is conducted by a physician deemed by the College of Physicians and Surgeons of Manitoba to be qualified to interpret ECGs. 3) The benefit for interpretation includes the written interpretation/report. 4) The benefits in this section apply to ECGs generated on equipment with a minimum capacity of 12 leads. 9836* Electrocardiogram, with interpretation and report twelve (12) leads * without interpretation and report twelve (12) leads * interpretation and report by physician who did not take tracing twelve (12) leads April 1, 2010 H-1

5 Nervous System STEREOTACTIC SURGERY FOR INTRACRANIAL LESIONS, CYSTS OR ABSCESSES 5107 Computed tomography guided stereotactic surgery for needle biopsy of intracranial lesions, and for drainage of intracranial cysts or abscesses, to include ventriculography with implantation and removal of radioactive sources in the brain, add Gamma Knife Radiosurgery Neurosurgery component ) Includes the review of submitted data, application of the stereotactic frame to the patient s head and revision and review of obtained images (either CT and/or MRI), the outline of the treatment plan and attendance with the patient for the duration of the radiosurgery. 2) This surgery should be done in conjunction with the radiation oncologist Gamma Knife Radiosurgery Radiation Oncology Component ) Includes entering data from CT scan into the treatment planning computer, determining the treatment plan and prescription with the radiotherapy physicist, responsibility for the administration of the single fraction radiosurgery and presence throughout the entire procedure. 2) This procedure is done in conjunction with the neurosurgeon. SPINE AND SPINAL CORD Laminotomy Lumbar See Arthrectomy 5201 Cordotomy, cervico-dorsal Percutaneous cordotomy (thermocoagulation technique), unilateral Intervertebral discs, excision anterior approach, cervical... 1, Laminectomy, for decompression of the spinal cord and nerve roots Laminectomy, for lesion of spinal cord or meninges each additional level, add to 5205 and/or Laminotomy, cervical Lumbar subarachnoid-peritoneal-ureteral shunt Meningocele, repair Meningomyelocele Rhizotomy Percutaneous implantation of neurostimulator electrodes, epidural or intradural Laminectomy for implantation of neurostimulator, epidural electrodes Incision and placement of subcutaneous neurostimulator/receiver (pack) Q-8 April 1, 2010