Who bills the fee: the hospital or the physician?
The physician fee (honorário médico) is billed by whoever the contract designates: the hospital, billing on behalf of the team, or the physician, billing the health plan (operadora) directly. The choice changes the form of the TISS standard (Troca de Informação de Saúde Suplementar, Brazil's health plan data exchange standard), the link between forms and the money flow, and it must be clear before surgery.
In hospital billing, the fee amount depends on the procedure's porte (complexity level), each physician's role, the procedures performed in the same session and any add-ons. In hospitals belonging to the National Association of Private Hospitals (Anahp), the “other operating revenue” line, which includes fees and bundles, was 26.13% of gross revenue in 2024 [8]. The Anahp Observatory does not break fees out of that line (Industry data).
| Situation | Who bills | Where it goes in TISS | Link |
|---|---|---|---|
| Inpatient, fee billed by the hospital | Hospital | Inpatient summary (resumo de internação, item 62.19) | Summary points to the admission request |
| Inpatient, physician bills directly | Physician or the physician's company | Physician fee form (guia de honorários, items 62.22 and 62.25) | Admission request only (item 62.26) |
| Outpatient SP/SADT, fee billed with it | SP/SADT provider | Professionals section of the same form, with the level (item 62.9) | — |
| SP/SADT, professional bills separately | Professional | Another SP/SADT, with the main form in field 3 (item 62.11) | Main form |
Source: TISS standard, Organizational Component 202609 [1].
TISS (Troca de Informações na Saúde Suplementar) is the mandatory data exchange standard set by Brazil's health plan regulator, the National Supplementary Health Agency (ANS). SP/SADT is the TISS form for outpatient services, exams and procedures. When the hospital bills, it receives payment from the health plan and passes it on to the team under its agreement with the medical staff. When the physician bills directly, the hospital still has to make sure the admission request number is right, because that is how the health plan matches the two claims [1]. Each form is covered in the TISS claim forms guide.
Participation level: each physician's code
The participation level (grau de participação) is the code in table 35 of TUSS (Unified Terminology for Supplementary Health, Brazil's standard code set) that states the professional's role in the procedure [2]. It goes with each professional on each procedure line and lets the health plan calculate each person's share.
| Code | Role | Code | Role |
|---|---|---|---|
| 00 | Surgeon | 07 | Anesthetist's assistant |
| 01 | First assistant | 08 | Consultant |
| 02 | Second assistant | 09 | Perfusionist |
| 03 | Third assistant | 10 | Pediatrician in the delivery room |
| 04 | Fourth assistant | 11 | SADT assistant |
| 05 | Scrub technician (instrumentador) | 12 | Clinician |
| 06 | Anesthetist | 13 | Intensivist |
Source: TUSS, table 35 [2].
Three checks matter most: a 00 code repeated on the same procedure, more assistants than the contract table allows (the number of assistants set for each procedure, in the Brazilian Hierarchical Classification of Medical Procedures, CBHPM), and a professional coded on the form who is missing from the operative report and the operating room log, with name and medical board number.
Surgical access, technique and type of care: what to report
Besides the level, each procedure line carries three items that change the amount: surgical access, technique and type of care. Each has its own TUSS domain table [3].
| Item | TUSS table | Codes | Effect on the amount |
|---|---|---|---|
| Surgical access (via de acesso) | 61 | 1 single · 2 same access · 3 different access | Sets the reduction for secondary procedures |
| Technique | 48 | 1 conventional · 2 video · 3 robotic | Identifies video procedures, which may have their own code and porte |
| Type of care (caráter do atendimento) | 23 | 1 elective · 2 urgent/emergency | Condition for the urgency add-on |
Source: TUSS, tables 61, 48 and 23 [3]. How to look up each table is covered in the TUSS code table guide.
The percentage applied to each line must appear on the form, in the field the health plan's manual specifies. Health plan filing manuals use this field differently: some ask for the urgency add-on there, others reserve it for multiple procedures. Follow each health plan's manual and contract.
How is each physician's fee calculated?
Each physician's amount comes from four steps: procedure porte, surgical access reduction, participation level percentage and add-ons. The reference table and percentages are the contract's, which Law 9,656/1998, art. 17-A, requires in writing, with the service values [7]. Contract clauses are covered in the Hospital-payer contract guide.
When the contract adopts the CBHPM, published by the Brazilian Medical Association (AMB), the edition must be fixed. The latest is the 2022 edition, sold by AMB [5]; the percentages below are from the 2012 edition, whose General Instructions are openly available on AMB's server [4]. CBHPM is not mandatory: Federal Council of Medicine (CFM) Resolution 1,673/2003, which adopted it as the minimum ethical standard, was revoked by CFM Resolution 2,293/2021 [6]. The edition and percentage written in the contract prevail.
| Rule (CBHPM 2012) | What it says | Item |
|---|---|---|
| Main procedure | The highest porte, through the access used, at 100% | 4.1 |
| Same access | Adds 50% of the porte of each secondary procedure, unless there is a code for the set | 4.1 |
| Different access | Adds 70% of the porte of each secondary procedure | 4.2 |
| Separate teams at the same time | Each team gets the porte of its own procedure | 4.4 |
| Act that is part of another | Only the main act is valued | 4.5 |
| Assistants | 1st assistant 30% of the surgeon's porte; 2nd and 3rd, 20%; 4th, 20% when the case requires | 5.1 |
| Assistants in multiple procedures | Number of assistants of the highest-porte procedure; percentage on the surgeon's total | 5.2 |
| Urgency and emergency | 30% more on the porte, from 7 p.m. to 7 a.m. and at any time on Saturdays, Sundays and holidays; applies if more than half of the act falls in that window | 2.1 |
| Higher-tier room | Porte doubled in higher-tier plans, for patients in a private room, day hospital or ICU; not for chapter IV, unless noted | 6.2 |
Source: AMB, CBHPM 2012, General Instructions [4].
See the example as a table
| Line | Calculation | Value |
|---|---|---|
| Procedure A, same access, surgeon (00) | 100% of BRL 1,000 | BRL 1,000 |
| Procedure B, same access, surgeon (00) | 50% of BRL 600 | BRL 300 |
| First assistant (01) | 30% of BRL 1,300 | BRL 390 |
| Second assistant (02) | 20% of BRL 1,300 | BRL 260 |
Example: two procedures through the same access
The example uses hypothetical values just to show the sequence; the percentages are from the 2012 edition [4]. A team performs, in the same session and through the same incision, one procedure whose porte is worth BRL 1,000 under the contract and another worth BRL 600, with no code for the set. The procedure allows two assistants.
| Line | Level (table 35) | Access (table 61) | Calculation | Amount |
|---|---|---|---|---|
| Procedure A, surgeon | 00 | 2 (same access) | 100% of BRL 1,000 | BRL 1,000 |
| Procedure B, surgeon | 00 | 2 (same access) | 50% of BRL 600 | BRL 300 |
| Team, first assistant | 01 | — | 30% of BRL 1,300 | BRL 390 |
| Team, second assistant | 02 | — | 20% of BRL 1,300 | BRL 260 |
Illustrative example; does not reflect any contract's values.
Assistants are calculated on the surgeon's total (BRL 1,300), under item 5.2 of the 2012 edition [4]; how to enter that on the lines follows the health plan's manual.
If the same surgery were urgent and performed at 10 p.m., the porte would carry 30% more, and the surgeon's fee would go from BRL 1,300 to BRL 1,690 [4]. Since the assistants' percentage applies to the surgeon's porte, check in the contract whether the add-on extends to the whole team.
Urgency and room add-ons: what the claim must show
An add-on is only paid when the claim proves the condition behind it. For urgency, the form must show type of care 2 (urgent/emergency) [3] and the start and end times of the act, consistent with the operating room log. Time alone is not enough: in the 2012 edition, the add-on applies to urgent or emergency acts performed in those windows [4]. An elective surgery scheduled at night does not get it.
For the room, the patient's plan is what counts: in the 2012 edition, the doubling applies to higher-tier plans (item 6.2), and a room chosen above the plan is negotiated between patient and physician (item 6.1) [4]. The proof is the room authorized on the admission request.
Both add-ons can apply to the same act. How to combine them (add the percentages or apply one on top of the other) is not in the 2012 General Instructions [4] and must be in the contract. Urgent care has its own coverage and billing rules: see the Urgent and emergency coverage and Emergency department billing guides.
Anesthetist, video and bundled fees: cases that need attention
Anesthetist (level 06). The amount comes from the procedure's anesthesia porte, a separate scale that the 2012 edition keeps at eight levels, matched to procedure portes (item 1.3) [4]. In the items on multiple procedures, assistants, urgency and room, the 2012 edition has no specific rule for the anesthetist [4]; the contract should set one. The anesthesia porte conversion is in the CBHPM guide.
Video surgery (technique 2). In the 2012 edition, the video procedure has its own porte, independent of the conventional one [4]. Reporting conventional technique and billing the video code, or the reverse, creates a mismatch between the form and the operative report.
Fees in a bundle. When the surgery is paid as a bundle (pacote), the contract must say whether fees are inside or outside it. Billing an included fee separately creates a duplicate. See the Hospital bundled pricing guide.
Five checks before submitting
The check compares the form with the record of the act and with the contract, before the health plan does.
| Check | What to verify | Supporting document |
|---|---|---|
| Form and link | Fee on the summary (hospital bills) or on the physician fee form (physician bills), with the admission request number | Contract and medical staff agreement |
| Team and level | 00 repeated on the same procedure; assistants within the limit; each name in the operative report and OR log | Operative report, OR log |
| Multiple procedures | Main procedure is the highest porte; access and technique reported; percentage of each secondary | Operative report with incisions and access |
| Add-ons | Type 2 and times within the window, for urgency; plan and authorized room, for doubling | OR log, admission request |
| Table and edition | Table edition, values and contract adjustments set up in the system | Health plan contract |
What the medical record must contain is in the Medical record audit guide. The cuts health plans make when one of these checks fails, with TUSS table 38 codes, are in the Physician fee denials guide (on denial, Brazil's term for claim denials).
What we see in operations
For physician fees, Accrua checks the surgical claim against the operative report, not just against the claim form. Accrua OS reads who took part, at what participation level, through which access route and with what technique, and compares it with what is being billed. A mismatched team, a missing assistant or an urgent case filled in as elective shows up before submission.
The calculation follows each health plan's contract: CBHPM edition, the rule for multiple procedures, the anesthesiologist rule and how urgency and room-type add-ons combine. These parameters are loaded by health plan, along with the physician fee denial history for that procedure.
Agents handle validation and submission. Correcting a participation level or an add-on that changes the value is a biller's or auditor's decision, made with the operative report and the clause in view. When the contract does not define one of these rules, the point is gathered for the hospital to take to negotiation.
Where to start
- Define, by contract and by team, who bills the fee: the hospital, on the inpatient summary, or the physician, on the physician fee form.
- Set up in the system the table edition, the access, assistant and add-on percentages and the anesthetist rule for each health plan.
- Standardize the operative report and OR log with team, level, access, technique and start and end times.
- Build an automated check for repeated 00 codes, number of assistants and type of care before submission.
- Review the filing manuals of your main health plans and record how each wants the reduction or add-on factor.