How to use our guidelines

Our multiple rules are calculated as 100% of the first procedure, 50% of the second procedure and 25% of the third procedure. This does apply to Outpatient, Day Patient and Inpatient

We no longer remunerate for more than three procedures in one theatre session as it is felt that any more than this would be a minor addition to, or part and parcel of the main procedure being carried out. 

Aviva is in line with the rest of the private medical insurance market. Should you have any queries regarding this change please contact us by email: avivapractitioners@aviva.com.

Introduction to Inappropriate Code Combinations

Some of the procedures listed in our fee schedule include other procedures that are also listed in their own right but are an integral part of the main procedure. We will not pay additional fees where a procedure is broken down into its separate components, where such an approach results in a higher overall charge.

We continue to work with healthcare providers and CCSD (Clinical and Coding Schedule Development) group to define inappropriate code combinations and welcome feedback to inform our approach. Please contact our Practitioner Management Team by email: avivapractitioners@aviva.com or by phone: 0800 015 7756.

To clarify why we deem some code combinations inappropriate, we have described six scenarios below:

• Impossible - procedures which are deemed unable to be performed together or, rarely, as a sole procedure.
• Minor additional - a procedure, additional to the main procedure, where the extra time taken to perform it is deemed insignificant (in relation to the main procedure) and hence no additional fee is justified.
• Part & parcel - a procedure which is so frequently performed as part of the main procedure that it forms an integral part of it.
• Mutually exclusive - procedures which are usually precluded from being performed together or are describing different methods of performing essentially the same operation.
• Another code - another code either more accurately describes the procedure or amalgamates different components of the procedure.
• Either/Or - both codes describe the same procedure, although may be different techniques or approaches.

No additional benefit is payable for the application of local anaesthesia and/or sedation where we consider this to be an integral part of the procedure based on accepted, standard medical practice. These procedures are indicated by an * in the schedule and the published fee is the maximum payable by us, inclusive of any anaesthesia and/or sedation used.

Aviva does however recognise that ongoing changes in medical practice mean that there are a growing number of occasions when a surgeon / anaesthetist will use a local anaesthetic and/or IV sedation for a procedure where in the past, general anaesthetic will have been used. In such circumstances an additional fee of 25% of the surgical units up to a maximum of £84 will be payable.

No additional fees for anaesthesia and/or sedation will be payable by us, for those procedures where no anaesthetic value is shown and which are not indicated by an * in the fee schedule.

No additional fees are payable for assistants, as assistants are considered to be employed by the specialist.

If a standby consultant (of another speciality) is to be used, written agreement to this should be requested from our Customer Service Department in advance of treatment. The clinical/medical reasons for such additional costs will be required but we will also later need written confirmation that the standby consultant was physically present during the entire procedure and had no other commitments during that time.

In those instances where a procedure requires specialists in two different disciplines to be present at the time of surgery, the lead surgeon should contact our Practitioner Management Team to advise the circumstances and gain agreement.

Aviva will not meet the cost of multi-disciplinary case conferences.

Routine pre-operative assessment of patients is included in the anaesthetic fee shown for each procedure. Where extensive pre-operative management is required or a consultation prior to admission is necessary, we may pay additional fees. You are advised to contact us in all such instances.

Expected and planned attendance by an anaesthetist during intensive care (eg post cardiac surgery) is covered by the anaesthetic fee for the operation as it will be part of the routine post-operative management including initiation of intravenous infusion for pain relief - ie PCA.

All fees quoted under anaesthetic units only apply when general anaesthesia has been administered. Please refer to the guidance on local anaesthesia/IV sedation when not using general anaesthetic.

Use of appropriate procedure codes

As a consultant it is your responsibility to code accurately and appropriately. Should you be in any doubt of the most appropriate code please contact our Practitioner Management Team on by email: avivapractitioners@aviva.com or by phone: 0800 015 7756.

Uncoded Procedures

Invoices must be coded using the industry standard CCSD code. If any procedure is undertaken which doesn't have a CCSD code, specialists should contact CCSD to request a new code (www.ccsd.org.uk) or contact the specialist relationships team at Aviva for more advice.

Please note we do not provide benefit for experimental or unproven procedures, including those using new technology or drugs, where safety and effectiveness have not been established or generally accepted by NICE (National Institute for Health and Care Excellence). Please contact the Practitioner Management Team for more advice.

Under NO circumstances should codes intended for existing procedures be used for new and un-coded procedures. The narratives and codes are protected by copyright and may not be altered or used in any other way. The use of alternative codes for un-coded procedures could be considered as fraudulent as this is coding for procedures not performed. Codes may be audited for clinical correctness.

Complex Surgery Cases

On occasion where Aviva’s published fee is not satisfactory for extreme circumstances, we have a process in place to consider more appropriate fees retrospectively. In order to review each case retrospectively we would require:

• Operation Notes
• Anaesthetic record
• Invoice for required fee for each surgeon
• Full and thorough clinical rationale/detailed reason why uplift is required

This information can be sent to the Practitioner Management Team by email: avivapractitioners@aviva.com.

Multiple Surgeon Procedures

If surgery is complex and requires dual/multiple surgeon approach please provide the details at the earliest opportunity to the Practitioner Management Team by email: avivapractitioners@aviva.com.

This would need to be pre-authorised, well in advance of the surgical date. Please submit along with your request the following documents/information. Please be aware that Aviva do not agree fees prior to surgery:

• Clinical Rationale for dual/multiple surgical necessity
• Relevant Clinical Letters
• MDT notes (if applicable)
• Full name of all surgeons
• Breakdown of procedure codes and fees each surgeon will be performing/billing for

This information can be sent to the Practitioner Management Team by email: avivapractitioners@aviva.com.