What is a physician fee denial?
A physician fee denial is a denial (claim denial) of all or part of the fees billed for the medical team: surgeon, assistants, anesthesiologist, attending physician, intensivist. The health plan (operadora) reports it on the claim remittance with a code from table 38 of TUSS (Unified Terminology for Supplementary Health), the national code set of ANS, Brazil's health plan regulator [1].
It is a specific case of hospital claim denials, with one difference: the fee is not fixed. It depends on the procedure's porte (complexity level), each physician's role, other procedures in the same act and add-ons, and each misapplied rule becomes a denial.
In 2024, “other operating revenue”, the line that includes physician fees and bundles, was 26.13% of gross revenue at hospitals of Anahp (National Association of Private Hospitals), with 119 reporting hospitals [7]. The report does not break fees out of that line.
How the fee is calculated (and where denials start)
Each physician's fee comes from a four-step calculation, and a denial appears when one step does not match what the plan accepts. It starts from the procedure's porte in the contract's reference table, usually CBHPM (Brazilian Hierarchical Classification of Medical Procedures), published by AMB, or the plan's own table. Then come each physician's team role, the reduction by surgical approach for multiple procedures and, last, urgency or room add-ons. Portes and UCO are covered in the CBHPM guide.
The percentages in this guide come from the 2012 CBHPM edition, whose full text is open on AMB's server [3]. The latest edition is 2022, sold by AMB and not consulted here. Its percentages may differ, and the edition set in the contract always applies.
See the flow as a table
| Step | Rule | Typical denials (table 38) |
|---|---|---|
| 1. Porte | Procedure code and porte in the contract table; act that is part of another: main one only | — |
| 2. Team role | Function in table 35 (00 surgeon to 13 intensivist); number of assistants allowed; team in the operative report | 3241, 2603 |
| 3. Surgical approach | Main procedure in full; others reduced (CBHPM 2012: 50% same approach, 70% different approach) | 2605, 1837 |
| 4. Add-ons | Urgency 30% from 7 pm to 7 am, weekends and holidays, urgent cases only; accommodation per the plan | 3309, 1747 |
What are the most common reasons for physician fee denials?
Almost every reason has its own message in TUSS table 38, used in claim responses under the TISS standard (Brazil's mandatory health data exchange standard) [4]. Descriptions are quoted in Portuguese from the ANS publication, with a translation.
| Code | Table 38 description | What is usually behind it | Document that answers it |
|---|---|---|---|
| 3241 | GRAU DE PARTICIPAÇÃO INFORMADO INCOMPATÍVEL COM O PROCEDIMENTO COBRADO (team role incompatible with the procedure billed) | More assistants than the procedure allows, or wrong table 35 code for the act | Contract table with number of assistants; operative report and OR log; corrected role on the form |
| 2603 | COBRANÇA DE HONORÁRIO SEM REGISTRO DA EFETIVA PARTICIPAÇÃO DO PROFISSIONAL (fee without record of participation) | Physician billed but not named in the operative report | Operative report and OR log listing the team |
| 2605 | NÃO CABE PAGAMENTO DO HONORÁRIO INTEGRAL POR SER A MESMA VIA DE ACESSO CIRÚRGICO (no full fee: same approach) | Second procedure billed at 100% | Operative report with incisions; contract multiple-procedure rule |
| 1837 | NÃO CABE PAGAMENTO DO HONORÁRIO INTEGRAL POR SER VIA DE ACESSO CIRÚRGICO DIFERENTE (no full fee: different approach) | Procedure through another approach billed at 100% | Same; proof of separate teams, if any |
| 3309 | URGÊNCIA/EMERGÊNCIA NÃO APLICÁVEL (urgency/emergency not applicable) | Add-on on a scheduled surgery or outside the time window | Correct type of care, start and end times in the OR log and urgency report |
| 1747 | PLANO DO BENEFICIÁRIO E O TIPO DE ACOMODAÇÃO NÃO PERMITEM ACRÉSCIMO DE HONORÁRIOS (plan and room type do not allow fee add-on) | Private-room add-on not covered by the plan | Eligibility and authorized accommodation |
There are also messages for anesthesia (1832, 1834), duplicate fees (2607) and a main procedure that does not require a medical team (2604) [1]. The codes in this section were checked in TUSS version 202607, the official ANS spreadsheet [1]. Each message is explained in the TISS denial codes guide.
Team role determines who gets paid and how much
The team role (grau de participação) is the code for the function each physician performed. TUSS table 35 lists 14 roles [2]: 00 surgeon; 01 to 04 first to fourth assistant; 05 scrub; 06 anesthesiologist; 07 anesthesiology assistant; 08 consultant; 09 perfusionist; 10 pediatrician in the delivery room; 11 diagnostic (SADT) assistant; 12 attending physician; 13 intensivist.
Role denials have three sources. The first two receive 3241: more assistants than the table allows for the procedure, and a wrong code for the act, such as two physicians coded as surgeon. The third is a billed physician who does not appear in the operative report or OR log (2603).
Assistant percentages vary by edition. In the 2012 CBHPM edition published by AMB, the first assistant receives 30% of the surgeon's porte, and the second, third and, when needed, fourth assistant 20% each [3]. Later editions, including 2022, may have changed these percentages; the edition set in the contract applies.
Surgical approach: the second procedure is not paid in full
With two or more procedures in the same act, the surgical approach rule reduces secondary procedures. In the 2012 CBHPM edition, through the same approach the main procedure's porte is added to 50% of each other procedure's porte; through different approaches, to 70% [3]. When different teams perform separate procedures at the same time, each team receives its own procedure's porte [3]. In multiple procedures, the number of paid assistants is that of the highest-porte procedure (item 5.2) [3]: an extra assistant billed because of the second procedure tends to come back with 3241.
Cuts usually come from three errors. The first is a secondary procedure billed at 100% (2605 or 1837). The second is an act that is an integral part of another billed separately, when CBHPM 2012 values only the main act [3]. The third is a different approach without proof, because the operative report does not record incisions or access routes. In the 2012 edition, video-assisted surgery has its own porte, separate from the open equivalent [3]; a video add-on not provided for receives 1829 [1].
Urgency and room add-ons: when they apply
Add-ons are denied when the claim does not prove the situation set in the table and the contract. In CBHPM 2012 [3]:
| Add-on | Rule in CBHPM 2012 | Typical denial | Proof |
|---|---|---|---|
| Urgency or emergency | 30% of the porte, from 7 pm to 7 am and any time on Saturdays, Sundays and holidays; an act started in normal hours qualifies if more than half falls in the urgency window | 3309 | Type of care “urgency/emergency” on the form; start and end times; physician report |
| Upgraded accommodation | Double porte only in higher-tier plans, for patients in a private room, day hospital or ICU; not for chapter IV, unless noted (item 6.2) | 1747 | Contracted and authorized accommodation; eligibility |
The urgency add-on depends on the type of care, not only the time: an elective surgery done at night does not qualify (3309). The room add-on depends on the plan: if the product covers a ward, the private-room add-on is denied (1747). Accommodation chosen voluntarily by the patient is a matter between patient and physician (item 6.1) [3]. A percentage different from the contract receives 1746 or 1716, and a visit by the surgical team within 10 days after surgery, already included in the porte (item 3.1), receives 1724 [1][3].
How to prevent physician fee denials before submission
Prevention means checking team, approach and add-ons against the record of the act before billing. Under TISS, fees billed by the hospital go on the inpatient summary form (item 62.19), and the fee form (guia de honorários) links only to the admission request (item 62.26) [4]. Details are in the TISS claim forms and Physician fees on hospital claims guides.
| Point | Question before submission | Denial if it fails |
|---|---|---|
| Team | Is every billed physician in the operative report and OR log, with the right role? | 2603, 3241 |
| Assistants | Does the number of assistants fit the procedure under the contract table? | 3241, 2604 |
| Multiple procedures | Is the main procedure the one with the highest porte? Are approaches described? | 2605, 1837 |
| Urgency | Is the type of care urgent, and is the time in the window? | 3309 |
| Accommodation | Do the plan and the authorization allow the add-on? | 1747 |
| Duplicates | Does each physician, for the same act, appear on one form only? | 2607 |
The foundation is a complete operative report (name, CRM medical license number and role of each team member, procedures, approaches, start and end times), consistent with the OR log. Contract rules also need to be configured in the billing system. What the record needs is in the Medical record audit guide.
How to appeal a physician fee denial
The appeal answers the code reported, with the document that proves the disputed point, through the TISS denial appeal messages [4].
- Read the code and justification. RN 503/2022 (ANS Normative Resolution on plan–provider contracts) bars plans from blocking access to denial justifications or blocking appeals, when billing follows the current TISS version [5].
- Separate rule denials from proof denials. A different edition or percentage is disputed with the contract; missing records, with the clinical document.
- Attach the right document: team (2603), approaches (2605, 1837), type of care and times (3309), authorized accommodation (1747).
- Meet the contract deadline. RN 503/2022 requires the contract to set appeal and response deadlines, with equal length, but sets no number of days [5].
- Log the outcome by code, plan and specialty. The full process is in the Denial appeal and Denial appeal deadlines guides.
What we see in operations
At Accrua, physician fee denials are read together with the operative report, because that is where the team, the access routes and the times are recorded. Accrua OS checks the degree of participation, the route and the add-ons billed against the authorized procedure, the CBHPM edition set in the contract with that health plan and the denial history for that code.
Before submission, anything that does not match becomes a task with the source shown: an assistant role that does not fit the procedure, a second procedure billed as the main one, an urgency add-on on an elective surgery. Changing an item that affects the value of the claim is a person's decision, not the system's.
When the denial arrives, the agent drafts the appeal with the relevant part of the operative report and the contract rule. If the health plan applied a different fee schedule edition from the one in the contract, the case is logged and goes to contract review. What we learn from one appeal becomes a check on the next claim.
Where to start
- Pull the last months' fee denials by table 38 code, plan and specialty.
- Check each contract for the reference table edition, deflators, multiple-procedure rule and accepted add-ons.
- Standardize the operative report with team, roles, approaches and times, consistent with the OR log.
- Build appeals by code, separating rule denials (contract) from proof denials (clinical record).