GR 6.9.7 is one of the most complex — and most commonly miscalculated — governing rules in Alberta's Schedule of Medical Benefits. It determines how fees are adjusted when a physician performs multiple procedures during the same encounter. Getting it right affects both revenue accuracy and audit defensibility.
When a physician performs more than one procedure in a single encounter, SOMB does not simply pay the full fee for each procedure. GR 6.9.7 defines the fee adjustment rules — which procedure gets full payment, which gets a reduced rate, and which may not be billable at all in combination.
The adjustment depends on:
SOMB classifies procedures into three tables for GR 6.9.7 purposes:
| Table | Description | Adjustment rule |
|---|---|---|
| Table 1 | Standard surgical procedures | Highest-fee procedure paid at 100%. Subsequent procedures adjusted based on incision classification. |
| Table 2 | Procedures with specific exception rules | Different adjustment rates may apply. Some Table 2 procedures have unique combination rules. |
| Table 3 | Additional benefit procedures | May be exempt from standard GR 6.9.7 adjustments in certain combinations. |
A key factor in GR 6.9.7 calculations is whether the multiple procedures share the same incision or use different incisions:
This distinction matters significantly for total encounter revenue. Incorrectly classifying same-incision procedures as different-incision (or vice versa) is a common billing error.
Some procedures classified as "additional benefit" codes are exempt from the standard GR 6.9.7 fee adjustments when performed alongside other procedures. These exemptions are defined in the SOMB and apply to specific code combinations.
Missing an additional benefit exemption means under-billing. Claiming an exemption that doesn't apply means audit risk.
Billing a procedure under the wrong table leads to incorrect fee calculations. Each code has a specific table assignment that must be referenced.
The distinction between same and different incision significantly affects the secondary procedure fee. Incorrectly classifying this changes the expected payment amount.
When a qualifying additional benefit procedure is combined with a primary procedure, the additional benefit code may be exempt from GR 6.9.7 adjustment. Not claiming the exemption means leaving money behind.
GR 6.9.7 adjustments are calculated based on the highest-fee procedure first. If procedures are ordered incorrectly, the total encounter fee may be calculated wrong.
Some physicians bill multiple procedures at full fee without applying GR 6.9.7 adjustments. This creates audit risk — the adjudicator will apply the adjustment, and the physician may face a clawback.
ABPhysCode automatically applies GR 6.9.7 logic when you build a multi-procedure encounter: