For an accurate, up-to-date reasonable and customary fee for any procedure, always check our Fee finder first.
We set our fees through a combination of looking at the market rate for a specific procedure and regular bench-marking, to ensure our fee structure accurately reflects the underlying factors including:
- A provider’s technical expertise, sub-speciality tertiary referrals and high-complexity case mix;
- The complexity and operating time of procedures, practice and professional costs;
- Market bench-marking
- Efficiency/utilisation levels, as well as the potential business risks associated with private practice, such as return on investment in property and equipment.
By carrying out this unique level of detailed bench-marking, it enables us to make sure we pay the right rate, as well as enabling you to evaluate your remuneration models, rather than simply relying on 'industry standards'.
On occasion our fees may not reflect genuinely exceptional circumstances. If you give us details of genuinely exceptional circumstances before invoices, we'll review the amount we pay: in cases where you anticipate that a particular surgical procedure may be more complex than usual: or in cases where you've spend longer than usual in surgery, due to unforeseen circumstances or complications.
- Common chronic conditions such as obesity or diabetes
- Claimed expertise in the given area (unless substantiated by valid published evidence and can demonstrate a material clinically significant impact on an individual basis for the insurer patient)
- Geographical or market availability reasons
- Lack of alternative comparative care available
- Dual surgeons fees driven by lack of experience in the UK and/or in contrast to international practice.
We often approve fee adjustments for valid reason. However, in cases where a revision to hourly rates would be difficult to justify to our 600,000 members, as well as the tens of thousands of clinicians who we work with, we reserve the right to reject any proposed increase.
From time to time, we may also challenge invoices. But in these cases, we’ll always work with you to find a rate that’s both fair to you and us. That’s because we believe good working relationships lead to better outcomes for us, you and most importantly, our members.
We provide consultants with a range of consultation and procedure fees based on the specialty and/or treatment code. We expect our recognised consultants to bill within this range, allowing variation for local factors. We also expect our consultants to treat Vitality members fairly, and recognising increasing insurance costs and our members' limited outpatient benefit, may not bill Vitality members any fees for any consultation or procedure which are higher than other major insurers they hold agreements with.
What fees should include:
- All pre and post-operative care
- The use of topical or infiltration anaesthesia or moderate conscious sedation
- Daily ward care for in-patient stay, including daily intensive care for procedures for which it is expected
- Pre-operative anaesthetic assessment
- Management of post-operative analgesia
- Management of commonly occurring minor complications in the perioperative period
- All follow-up consultations occurring within the first 28 days after the date of surgery
What we’ll pay:
- Fees that don’t go over our reasonable and customary rates for procedures we authorise in advance;
- For continuous regional anaesthesia e.g. brachial plexus block, epidural block where performed by the operator, and only in the absence of general anaesthesia. the multiple procedure billing rules should be followed
- For continuous epidural blockade, or major nerve or plexus blockade after localisation, performed by an anaesthetist in addition to general anaesthesia. The multiple procedure rules should be followed
- Fees of a standby recognised consultant where there is written and exceptional motivation for the clinical need received at least 72 hours in advance of the procedure and this is agreed in writing by us
What we may pay:
- Fees that exceed our guidelines for procedures that have been unusually complex and have been agreed by us at least 72 hours in writing in advance of invoicing
- Fees of a second consultant where the procedure is unusually complex, where clinical guidelines from a UK national professional body or another entity we accept support surgery as a two-surgeon procedure, and this has been agreed by us in writing in at least 72 hours in advance of the procedure
- Fees of one or more Recognised Consultant(s) for urgent care where the treatment is unusually complex, which has been agreed by us in advance and as soon as is reasonably practical
- Exclusively at our discretion and on a named individual basis, for procedures that are experimental, provided there is evidence of their safety and efficacy, and they are performed as part of a properly conducted clinical trial, and they are discussed with and agreed by us in writing, at least 72 hours in advance of the care, and/or have been agreed in writing with the hospital Medical Advisory Committee
- For pathology services by a privately owned and managed clinic/consulting room where we have a specific written agreement in place with the clinic/ consulting room which includes fees and conduct
- For other exceptional agreements exclusively on a one-off basis.
What we won't pay:
- Recognised Consultants who are surgeons fees for local anaesthesia where an anaesthetist has also provided anaesthesia
- For additional procedures that are integral to the procedure(s) being performed (unbundling). For examples, please see the section on unbundling or visit www.ccsd.org.uk/CCSDSchedule
- Fees of surgical assistants
- For routine postoperative care, including daily visiting and separate charges for follow-up consultations in the first 28 days after the date of surgery
- Fees for consultations by radiologists, anaesthetists, or pathologists
- Recognised Consultant fees for histopathology or diagnostic imaging in a private hospital
- Fees for pathology when the billing provider did not provide the service
- Fees for interpretation of any diagnostic tests, when the Recognised Consultant did not perform the diagnostic test themselves, or where a hospital facility has invoiced for a test which includes, or is reasonably expected to include, a Recognised Consultant component
- Fees for consultations on the same day as a day case or in-patient procedure
- Fees for any tests or procedures which do not require the use of any specialised or surgical equipment
- Fees for remote monitoring
- Phlebotomy
- Fees for any other care that does not involve a definite consultation, or fees for a procedure where no appropriate CCSD code exists, unless explicitly agreed in writing in advance
- Any other ineligible treatment
- Fees for correspondence and reports provided required for assessing the eligibility for funding of a claim
Our fee structure allows you to carry out more than one procedure on a member during the same operating session. In these cases, we will normally increase payments by a percentage of the most complex procedure. In exceptional circumstances, we may pay up to 100% of the fee for each procedure you carry out.
The following rules apply:
- Where the same operator carries out two procedures during the same operating session, we’ll pay up to 25% over and above the maximum for the most complex procedure;
- Where the same operator carries out three or more procedures during the same operating session, we’ll pay up to 40% over and above the maximum for the most complex procedure;
- We will only consider payment for more than three procedures in exceptional circumstances;
- We will only pay the fee of the primary consultant in cases where one consultant assists another;
- Where an operator carries out two different procedures on the same day but not in the same operating session, we’ll pay up to 100% of the eligible maximum for both procedures;
- We won’t consider paying for unbundled procedures in any circumstances.
Bilateral procedures
There are specific CCSD codes for procedures commonly or invariably performed bilaterally. If a code exists for a bilateral procedure - e.g. Bilateral mastectomy – we’ll pay up to the fee maximum for that code only. Where there’s no bilateral procedure code, the multiple rules apply.
Complex surgical procedures
If you give us details of complications or unusual circumstances before invoicing, we’ll review the amount we pay: in cases where you anticipate that a particular surgical procedure may be more complex than usual; or in cases where you’ve spent longer than usual in surgery, due to unforeseen circumstances or complications.
We define unbundling as the breaking down of a surgical procedure into components normally considered part of that procedure and then charging for each
component in addition. Therefore, we won’t pay additionally for:
Procedures considered integral to a specific procedure - for example:
- Osteotomy of long bone during total hip replacement;
- Cardiac catheterisation prior to coronary angioplasty;
- Diagnostic arthroscopy with therapeutic arthroscopic procedures;
- Bilateral oophorectomy and salpingectomy as part of total abdominal hysterectomy;
- Endoscopic examination of ureter with endoscopic retrograde pyelography;
- Radiographic imaging for procedures usually performed under X-ray control.
Procedures integral to a wide range of procedures - for example:
- Insertion of intravenous access for medication administration;
- Phlebotomy;
- Primary suturing of a wound and removal of sutures;
- Application and management of post-operative dressings and analgesic devices (e.g. patient controlled analgesia).
Procedures for gaining access to the target organ system or operation site - for example:
- Clearance of impacted wax prior to myringotomy
- Adhesiolysis or exploratory laparotomy prior to intra-abdominal procedures;
- Urethroscopy or cystoscopy with other endoscopic intravesical or nephro-ureteric procedures;
- Bronchoscopy prior to thoracic surgery where the diagnosis has already been established.
Endoscopic procedures done as part of an open procedure or converted to an open procedure - for example:
- Laparoscopic cholecystectomy converted to an open procedure.
Procedures for postoperative analgesia performed by the operator under general anaesthesia
- Codes W9030, W9040, W9012, W9013, W9014, W9015, S5210, A7350 and AC100 won’t be accepted.
Procedures additional to a procedure specified as 'as sole procedure'
- You can’t use codes that the CCSD narrative classifies 'as sole procedure' in combination with any other code, except for procedures performed at
completely different anatomical sites.
