(i) The Employee and the Doctor
The employee is permitted to choose freely his own doctor, and no interference with this privilege is permitted as long as it is exercised reasonably and without prejudice to the employee himself or the Compensation Fund. The only exceptions to this rule are those cases where employers, with the Compensation Commissioner's approval, provide their own medical aid facilities in toto, i.e. including hospital, nursing and other services - section 78 of the Act.
In terms of section 42 either the Compensation Commissioner or an employer may send the injured employee to another doctor chosen by him (Compensation Commissioner or employer) for a special examination and report. Special fees are payable for this service.
In the event of a change of doctors attending a case, the first doctor in attendance will, except where the case is handed over to a specialist, be regarded as the principal, and payment will normally be made to him. To avoid disputes, doctors should refrain from treating a case already under treatment without first discussing it with the first doctor. As a general rule, changes of doctor are not favoured, unless there are sufficient reasons therefore.
If an injured employee is in need of emergency treatment, the doctor should act in the same manner as he would to any patient who needs his urgent help. He should not, however, ask the Compensation Commissioner to authorise such treatment before the claim has been admitted as falling within the scope of the Act. It should be remembered that an employee seeks medical advice at his own risk. If, therefore, an employee represents to his doctor that he is a Compensation for Occupational Injuries and Diseases Act case and yet fails to claim the benefits of the Act, leaving the Compensation Commissioner, or his employer, in ignorance of any possible grounds for a claim, the insurance fund concerned cannot accept any responsibility for any medical expenses incurred. In such circumstances the employee would be in the same position as any other member of the public as regards payment of his medical expenses.
(ii) Except where otherwise stated the fees charged for services of a general practitioner shall be two-thirds of the fees of the specialist for the same service.
(iii) Monetary values have been rounded off to the nearest 10 cents on the basis that monetary values ending with a 1 to 4 cents value must be rounded off to the lower zero, and that 5 to 9 cents must be rounded off to the upper zero.
A. Consultations: Definitions
(i) First consultation: Refers to a situation where a medical practitioner personally takes down a patient's medical history, performs an appropriate clinical examination and, if indicated, prescribes or administers treatment.
(ii) Subsequent consultation: Refers to a voluntarily scheduled consultation performed for the same condition within four (4) months after the first consultation (although the symptoms or complaints may differ from those presented during the first consultation). It may imply taking down a medical history and/or a clinical examination and/or prescribing or administering of treatment and/or counselling.
(iii) Hospital visits: Where a procedure or operation was done, hospital visits are regarded as part of the normal after-care and no fees may be levied. Where no procedure or operation was carried out fees may be charged for hospital visits according to item 0109. Dates of hospital visits must be specified.
B. Normal hours versus after-hours: Normal working hours refer to the period 08:00 to 17:00 on Mondays to Fridays; the period 08:00 to 13:00 on Saturdays; as well as all other periods voluntarily scheduled (even when for the convenience of the patient) by a medical practitioner for the rendering of services. All other periods are regarded as after-hours. Public holidays are not regarded as normal working days and involuntarily scheduled work performed on such days is regarded as after-hours work. Services are scheduled involuntarily for a specific time, if for medical reasons the doctor should not render the service at an earlier or later opportunity.
C. The fee that may be charged in respect of the rendering of a service not listed in this tariff of fees shall be based on the fee in respect of a comparable service.
D. Unless timely steps are taken to cancel an appointment for a consultation the relevant consultation fee shall be payable by the employee. In the case of a general practitioner "timely" shall mean two hours and in the case of a specialist 24 hours prior to the appointment. Each case shall however, be considered on merit and, if circumstances warrant, no fee shall be charged.
E. The appropriate fee may be charged for all pre-operative consultations with the exception of a routine pre-operative visit at the hospital.
F. Where applicable fees for administering injections and/or infusions may only be charged when done by the practitioner himself.
G.
(a) Unless otherwise stated, the fee in respect of an operation or procedure shall include normal after-care for a period not exceeding four months (after-care is excluded from pure diagnostic procedures during which no therapeutic procedures were performed).
(b) If the normal after-care is delegated to any other registered health professional and not completed by the surgeon, it shall be his/her own responsibility to arrange for this to be done without extra charge.
(c) When the care of post-operative treatment of a prolonged or specialised nature is required, such fee as may be agreed upon between the surgeon and the scheme or the patient (in case of a private account) may be charged.
(d) Normal after-care refers to an uncomplicated post-operative period not requiring any further incisions.
H. Items involving removal of lesions include follow-up treatment for four months.
I. Fees for all pathology investigations performed by members of other disciplines (where permissible): See section for Pathology. (Refer to M 0097).
J. In exceptional cases where the tariff fee is disproportionately low in relation to the actual services rendered by a medical practitioner, a higher fee may be negotiated. Conversely, if the fee is disproportionately high in relation to the actual services rendered, a lower fee than that in the tariff should be charged.
K. Save in exceptional cases the services of a specialist shall be available only on the recommendation of the attending general practitioner. Medical practitioners referring cases to other medical practitioners shall, if known to them, indicate in the reference that the patient was injured in an "accident" and this shall also apply in respect of specimens sent to pathologists.
L. If a procedure is performed at the time of an initial or subsequent consultation, the fee for the consultation plus the fee for the procedure is charged.
M. If such a procedure, planned at an initial or subsequent consultation, is performed at another time, the fee for the procedure only is charged.
N.
(a) No additional fee may be charged for a service for which the fee is indicated as "per consultation". Such services are regarded as part of the consultation performed at the time the condition is brought to the doctor's attention.
(b) Where a fee for any service is prescribed herein, the medical practitioner shall not be entitled to payment calculated on a basis of visits or examinations made where such calculation would result in the prescribed fee being exceeded.
(c) The number of consultations must be in direct relation to the seriousness of the injury and should more than 20 consultations be necessary, the Compensation Commissioner must be furnished, with a detailed motivation. (d) A single fee for a consultation/visit shall be paid to a medical practitioner who gives a single treatment to an injured employee who thereafter passes to the permanent care of another medical practitioner, not being a partner or assistant of the first. The responsibility for furnishing the first medical report in such a case ordinarily rests with the second practitioner.
O.
(a) An employee should be hospitalised only if and for such a period his condition justifies full-time "medical aid".
(b) Occupational therapy/Physiotherapy. The same principles set out in modifier 0077 will apply when an employee is referred to a therapist.
(c) In the case of costly or prolonged medical services or procedures the medical practitioner shall first ascertain in writing from the Compensation Commissioner for what amount the Compensation Commissioner will accept responsibility in respect of such treatment.
P. Travelling fees
(a) Where, in cases of emergency, a practitioner was called out from his residence or rooms to an employees home or the hospital, travelling fees can be charged according to Section IV if he had, to travel more than 16 kilometres in total.
(b) If more than one employee would be attended to during the course of a trip, the full travelling expenses must be divided pro rata between the relevant employees.
(c) A practitioner is not entitled to charge for any travelling expenses or travelling time to his rooms.
(d) Where a practitioner's residence would be more than 8 kilometres away from a hospital, no travelling fees may be charged for services rendered at such hospitals, except in cases of emergency (services not voluntarily scheduled).
(e) Where a practitioner conducts an itinerant practice, he is not entitled to charge fees for travelling expenses except in cases of emergency (services not voluntarily scheduled).
Intensive Care
Q. Units in respect of items 1204 to 1210 exclude the following:
(a) Anaesthetic and/or surgical fees for any condition or procedure, as well as a first consultation, which is regarded as the assessment of the patient, while the daily intensive fee covers the daily care in the intensive care unit.
(b) Costs of any drugs and/or materials.
(c) Any other cost which may be incurred before, during or after the consultation and/or the therapy.
(d) Blood gasses and chemistry tests, including the arterial puncture to obtain the specimen.
(e) Procedural items 1212 to 1219, but including the following:
(f) Performing and interpretation of a resting ECG.
(g) Interpretation of chemistry test and x-rays.
(h) Intravenous treatment (items 0206 and 0207).
R. Units for items 1208, 1209 and 1210 include resuscitation (i.e. item 1211).
S. Units for items 1212, 1213 and 1214 include the following:
(a) Measurement of minute volume, vital capacity, time and vital capacity studies.
(b) Testing and connecting the machine.
(c) Putting patient on machine: Setting machine, synchronising patient with machine.
(d) Instruction to nursing staff.
(e) All subsequent visits within 24 hours.
T. Ventilation (items 1212 to 1214) does not form a part of normal post-operative care.
U. Magnetic Resonance Imaging
Note: In cases where a second Magnetic Resonance Imaging of the spine (items 6210, 6211, 6212 and 6213 refers) is deemed necessary, or a Magnetic Resonance Imaging of another anatomical region is requested, proper motivation must be submitted upon which the Commissioner will consider approval.
Item 6270 - Proper motivation must be submitted upon which the Commissioner will consider approval.
0001 For involuntarily scheduled after-hours emergency radiological services, the additional premium shall be 50% of the fee for the particular services (section 19.12 excluded). See general rule B. For after-hours MR scans, a maximum levy of 100,00 radiological units (R781.10) is applicable.
0002 Item 38/0101: First consultation: Normal hours: At a doctor’s room or home: Radiologist, is applicable only where a radiologist is requested to give a written report on x-rays taken elsewhere and submitted to him. This item and item 0103 are not to be used for routine reporting of x-rays taken elsewhere.
0005 Multiple procedures/operations under the same anaesthetic.
(a) Unless otherwise identified in the tariff when multiple procedures/operations add significant time and/or complexity, and when each procedure/operation is clearly identified and defined, the following values shall prevail: 100% (full value) for the first or major procedure/operation, plus 50% (half of) the tariff fee in respect of each additional operation or procedure with a maximum of four additional operations or procedures.
(b) In the case of multiple fractures and/or dislocations the same values shall prevail.
(c) When purely endoscopic diagnostic procedures or diagnostic endoscopic procedures unrelated to any therapeutic procedures performed, are performed under the same general anaesthetic, modifier 0005 is not applicable to the fees for such diagnostic endoscopic procedures as the fees for endoscopic procedures do not provide for after-care. Specify unrelated endoscopic procedure and provide diagnosis to indicate diagnostic endoscopic procedure(s) unrelated to other (therapeutic) procedures performed under the same anaesthetic.
(d) Please note: When more than one small procedure is performed and the tariff makes provision for items for "subsequent" or "maximum for multiple additional procedures" (see section 2. Integumentary System) modifier 0005 is not applicable as the fee is already a reduced fee.
Note: In the case of multiple fractures and/or dislocations the same values shall prevail.
0006 A 25% reduction in the fee for a subsequent operation for the same condition within one month shall be applicable if the operations are performed by the same surgeon (an operation subsequent to a diagnostic procedure is excluded). After a period of one month the full fee is applicable.
0007
(a) Remuneration for the use of any type of own equipment in the rooms for procedures performed under intravenous sedation or for procedures performed in a hospital or day-clinic theatre when appropriate equipment is not provided by the hospital - 15,00 clinical procedure units (R114.00) irrespective of the number of items of equipment provided.
(b) Remuneration for the use of any type of own equipment for procedures performed in a hospital theatre or unattached theatre unit when appropriate equipment is not provided by the hospital - 15,00 clinical units (R114.00) irrespective of the number of items of equipment provided.
0008 Where a procedure requires a registered specialist surgeon assistant, the fee is 33,33% (1/3) of the fee for the specialist surgeon.
0009 The fee for an assistant is 20% of the fee for the specialist surgeon, with a minimum of 36,00 clinical procedure units (R273.50).
0010 A fee for a local anaesthetic administered by the operator may only be charged for an operation or a procedure having a value greater than 30,00 clinical procedure units (i.e. 31,00 or more units - R235.50 - allocated to a single item). The fee shall be calculated according to the basic anaesthetic fees for the specific operations. Anaesthetics time may not be charged for, but the minimum fee as per modifier 0036 shall be applicable in such a case. Not applicable to radiological procedures (such as angiography and myelography). No fee may be levied for topical application of local anaesthetic. Please note: modifier 0010 may not be added to the surgeon's account for procedures that were performed under general anaesthetic.
0011 Emergency surgery for theatre procedures: Any bona fide, justofiable emergency procedure (all hours) (for IOD patients only applicable during after-hour periods only - see general rule B) undertaken in a operating theatre will attract an additional 12,00 clinical procedure units (R91.20) per half-hour or part thereof of the operating time for all members of the surgical team. This does not apply in respect of patients on scheduled lists.
0013 Endoscopic examinations done at operations: Where a related endoscopic examination is done at an operation by the operating surgeon or the attending anaesthesiologist, only 50% of the fee for the endoscopic examination may be charged.
0014 Where an operation is performed which has been previously performed by another surgeon, e.g. a revision or repeat operation, the fee shall be calculated according to the tariff for the full operation plus an additional fee to be negotiated under General Rule J, except where already specified in the tariff.
0015 Where intravenous infusions (including blood and blood cellular products) are administered as part of the after-treatment after operation, no extra fees will be charged as this is included in the global operative fees. Should the practitioner doing the operation prefer to ask another practitioner to perform post operative intravenous infusions, then the practitioner himself (and not the patient) is responsible for remunerating such practitioner for the infusions.
0017 Where desensitisation, intravenous, intra-muscular or subcutaneous injections are administered by the doctor himself in respect of patients who attend the consulting rooms, a first injection forms part of the consultation and all subsequent injections for the same condition should be charged at 50% of the appropriate consultation fee in accordance with general practice schedule.
0021 Anaesthetic fees are determined by obtaining the sum of the BASIC ANAESTHETIC UNITS AND THE TIME UNITS. IN CASES OF OPERATIVE PROCEDURES ON THE MUSCULO-SKELETAL SYSTEM, OPEN FRACTURES AND OPEN REDUCTION OF FRACTURES OR DISLOCATIONS ADD FEES AS LAID DOWN BY MODIFIERS 5441 TO 5448.
0023 The basic anaesthetic units are laid down in the tariff. These basic anaesthetic units reflect the additional anaesthetic risk, the technical skill required of the anaesthesiologist and the scope of the surgical procedure, but exclude the value of the actual time spent administering the anaesthetic. The time units (indicated by "T") will be added to the listed basic anaesthetic units in all cases on the following basis:
Anaesthetic time: The remuneration for anaesthetic time shall be per 15 minute period or part thereof, calculated from the commencement of the anaesthetic e.g. 2,00 anaesthetic units (R71.00) per 15 minute period or part thereof, provided that should the duration of the anaesthetic be longer than one hour the fee shall, after one hour be 3,00 anaesthetic units (R106.60) per 15 minute period or part thereof.
0024 If a pre-operative assessment of a patient by the anaesthesiologist, is not followed by an operation it will be regarded as consultation at the hospital or nursing home.
0025 Anaesthetic time is calculated from the time the anaesthesiologist begins to prepare the patient for the induction of anaesthesia in the operating theatre or in a similar equivalent area and ends when the anaesthesiologist is no longer required to give his personal professional attention to the patient, i.e. when the patient may, with reasonable safety, be placed under the customary post-operative supervision. Where prolonged personal professional attention is necessary for the well-being and safety of such patient, the necessary time will be valued on the same basis as indicated above for anaesthetic time. The anaesthesiologist must show in his account the exact anaesthetic time and the supervision time spent with the patient.
0027 Where more than one operation is performed under the same anaesthetic, the basic value will be that of the major operation with the highest unit value.
0029 When rendered necessary by the scope of the anaesthetic an assistant anaesthesiologist may be employed. The remuneration of the assistant anaesthesiologist shall be calculated on the same basis as in the case where a general practitioner administers the anaesthetic.
0031 Treatment with intravenous drips and transfusions is considered part of the normal treatment in administering an anaesthetic. No additional fees may be charged for such services when rendered either prior to, or during actual theatre or operating time.
0032 Anaesthesia administered to patients in the prone position shall have a minimum of 4,00 basic anaesthetic units (R142.10).
0033 When an anaesthesiologist is required to participate in the general care of a patient during a surgical procedure, but does not administer the anaesthetic, such services may be remunerated at full anaesthetic rate, subject to the provisions of modifier 0035.
0034 All anaesthetic administered for diagnostic, surgical or X-ray procedures on the head and neck shall have a minimum of 4,00 basic anaesthetic units (R142.10). When the basic anaesthetic units for the procedure is 3,00, one extra anaesthetic unit should be added. If the basic anaesthetic units for the procedure is 4,00 or more, no extra units should be added.
0035 No anaesthetic administered by a specialist anaesthesiologist shall have a total value of less than 7,00 anaesthetic units (R248.70).
0036 Fees for an anaesthetic administered by a general practitioner shall be two-thirds of the total number of units applicable to the specialist anaesthesiologist provided that no anaesthetic shall have a total value of less than 6,00 anaesthetic units (R213.10). The monetary value of the unit is the same for both a specialist anaesthesiologist and a general practitioner anaesthesiologist.
Note: Modifying units may be added to the basic unit value according to the following table.
0037 Utilisation of total body hypothermia: Add 3,00 anaesthetic units (R106.60).
0038 Peri-operative blood salvage: Add 4,00 anaesthetic units (R142.10) for intraoperative blood salvage and 4,00 anaesthetic units for post-operative blood salvage.
0039 Deliberate control of the blood pressure: All cases up to one hour add 3,00 anaesthetic units (R106.60) thereafter add 1 (one) additional anaesthetic unit (R35.50) per quarter hour or part thereof.
0041 Utilisation of hyperbaric pressurisation: Add 3,00 basic anaesthetic units (R106.60).
0042 Utilisation of extracorporal circulation: Add 3,00 anaesthetic units (R106.60).
Modifiers 5441 to 5448 - General practitioners refer to M 0036 (two-thirds).
Modification of the anaesthetic fee in cases of operative procedures on the musculo-skeletal system, open fractures and open reduction of fractures and dislocations is governed by adding units indicated by modifiers 5441 to 5448. (The letter "M" is annotated next to the number of units of the appropriate items, for facilitating identification of the relevant items).
5441 In all cases of open fractures, open reduction of fractures and dislocations: Add ONE anaesthetic unit (R35.50) except where the procedure refers to the bones named in Modifiers 5442 to 5448.
5442 Shoulder, scapula, clavicle, humerus, elbow joint, upper 1/3 tibia, knee joint, patella, mandible and temporo-mandibular joint: Add TWO anaesthetic units (R71.00).
5443 Maxillary and orbital bones: Add THREE anaesthetic units (R106.60).
5444 Shaft of femur: Add FOUR anaesthetic units (R142.10).
5445 Spine (except coccyx), pelvis, hip, neck of femur: Add FIVE anaesthetic units (R177.60).
5448 Sternum and/or ribs and musculo-skeletal procedures which involve an intra-thoracic approach: Add EIGHT anaesthetic units (R284.20).
0045 Where the anaesthesiologist has personally administered the anaesthetic, post-operative alleviation of pain, where special techniques are required, shall be charged according to item 0109 (subsequent visit at the hospital).
Where the anaesthetic was administered by another anaesthesiologist post-operative alleviation of pain employing special techniques shall be charged according to the particular procedure for instituting the therapy. Revisits shall be charged according to item 0109.
None of the above is applicable to routine post-operative pain management.
0046 Where in the treatment of a specific fracture or dislocation (compound or closed) an initial procedure is followed within one month by an open reduction, internal fixation, external skeletal fixation or bone grafting on the same bone, the fee for the initial treatment of that fracture or dislocation shall be reduced by 50%. Please note: This reduction does not include the assistant's fee or the after-hours levy where applicable. After one month, a full fee as for the initial treatment, is applicable.
0047 A fracture NOT requiring reduction shall be charged on a fee for service basis PROVIDED that the cumulative amount does NOT exceed the charges for a reduction.
0048 Where in the treatment of a fracture or dislocation an initial closed reduction is followed within one month by further closed reductions under general anaesthesia, the fee for such subsequent reductions will be 27,00 clinical procedure units (R205.10) (not including after-care).
0049 Except where otherwise specified, in cases of compound fractures, 77,00 clinical procedure units (R585.00) (specialists) and 51,00 clinical procedure units (R387.40) (general practitioners) are to be added to the fees for the fractures, including debridement.
0050 In cases of a compound fracture where a debridement is followed by internal fixation (excluding fixation with Kirschner wires and excluding fractures of hands and feet), the full amount according to either modifier 0049 or 0051 may be added to the fee for the procedure involved, plus half of the amount according to the second modifier (either 0049 or 0051 as applicable).
0051 Except where otherwise specified in cases of fractures requiring open reduction, internal fixation, external skeletal fixation and or bone grafting: Add 77,00 clinical procedure units (R585.00) (specialists) and 51,00 clinical procedure units (R387.40) (general practitioners).
0053 Fractures requiring percutaneous internal fixation: [Insertion and removal of fixatives (wires) in respect of fingers and toes included)]: Add 32,00 clinical procedure units (R243.10) (specialists) and (general practitioners) add 21,00 clinical procedure units (R159.60).
0055 Dislocation requiring open reduction: Fee for the specific joint plus 77,00 clinical procedure units (R585.00) (specialists) and 51,00 clinical procedure units (R387.40) (general practitioners).
0057 In multiple procedures on feet, fees for the first foot are calculated according to modifier 0005. Calculate fees for the second foot in the same way, reduce the total to 50% and add to the total for the first foot.
0058 Revision operation for total joint replacement and immediate resubstitution (infected or non-infected): Per fee for total joint replacement + 100%.
0061 In cases of combined procedures on the spine, both the orthopaedic surgeon and the neurosurgeon are entitled to the full fee for the relevant part of the operation performed.
0063 Where two specialists work together on a replantation procedure, each shall be entitled to two-thirds of the fee for the procedure.
0064 Where the replantation or toe to thumb transfer is unsuccessful, no further surgical fee is payable for amputation of the non-viable parts.
0067 Micro-surgery of the larynx: To the fee of the operation performed add 25%. For other operations requiring the use of an operation microscope, the fee shall include the use of the microscope, except where otherwise specified elsewhere in the Tariff.
0069 When endoscopic instruments are used during intra-nasal surgery: Add 10% of the fee of the procedure performed. Only applicable to items 1025, 1027 and 1035.
0070 A reduction of 33,33% (1/3) of the fee will apply to the pulmonary function tests as indicated in section 4.6.2 where hospital equipment is used.
0074 A reduction of 33,33% (1/3) (one third) of the fee will apply to all fibre optic procedure performed by means of hospital equipment.
0075 The fee plus 21,00 clinical procedure units (R159.50) will apply where fibre optic procedures are performed in rooms with own equipment. Please note: Modifier 0075 is not applicable to any of the items for diagnostic procedures in the otorhinolaryngology sections of the tariff.
0077
a) When two separate areas are treated simultaneously for totally different conditions, such treatment shall be regarded as two treatments for which separate fees may be charged. (Only applicable if services are provided by a specialist in physical medicine).
b) The number of treatments to a patient for which the Commissioner shall accept responsibility is limited to 20. If further treatments are necessary payment therefore must be arranged with the Commissioner.
0079 If a first consultation proceeds into, or is immediately followed by a medical psychotherapeutic procedure, fees for the procedure shall be calculated at 24,00 clinical procedure units (R182.30) per 20 minute session or part thereof, provided that such a part comprises 50% or more of the time of a session.
0001 For involuntarily scheduled after-hours emergency radiological services, the additional premium shall be 50% of the fee for the particular services (section 19.12 excluded). See general rule B.
For after-hours MR scans, a maximum levy of 100,00 radiological units (R781.10) is applicable.
0002 Item 38/0101 is applicable only where a radiologist is requested to give a written report on X-rays taken elsewhere and submitted to him.
0080 Multiple examinations: Full fee.
0081 Repeat examinations: No reduction.
0082 "+" Means that this item is complementary to a preceding item and is therefore not subject to reduction.
0083 When a Radiologist makes use of hospital equipment, only 66,67% (2/3) of the fee for the examination is chargeable.
0084 In the case of radiological items where films are used practitioners should adjust the fee upwards or downwards in accordance with changes in the price of films in comparison with January 1995; the calculation must be done on the basis that film costs comprise 10% of the monetary value of the unit.
0086 Vascular groups: "Film series" and "Introduction of Contrast Media" are complementary and together constitute a single examination: Neither fee is therefore subjected to reduction (Modifier 0080).
See modifier 0160 under paragraph 19.11.
0090 Radiologist’s fee for participation in a team: 30,00 radiological units (R234.30) per half hour or part thereof for all interventional radiological procedures, excluding any pre- or post-operative angiography, catheterisation, CT-scanning, ultrasound scanning or X-ray procedures.
0093 The fees for Radiation oncology shall apply only where a specialist in radiotherapy uses his own apparatus.
0097 Where items under Pathology and Anatomical Pathology fall within the province of other specialists or general practitioners, the fee is to be charged at two thirds of the pathologist's fee.
0099 For tests performed on a stat basis, an additional premium of 50% of the fee for the particular pathology service shall apply, with the following provisos:
Stat test requesting may only be done by the referring practitioner and not by the pathologist.
Specimens must be collected on a stat basis where applicable.
Test must be performed on a stat basis.
Documentation (or a copy thereof) relating to the request of the referring practitioner must be retained.
This modifier will only apply during normal working hours and will never be used in combination with item 4547.
0100 Where an anaesthesiologist would be responsible for operating an intra-aortic balloon pump, a fee of 75,00 clinical procedure units (R569.80) is applicable.
0102 Pre-operative assessment in ward (includes emergency cases where doctor does not travel) (includes the interpretation of an ECG and/or lung function test).
0105 Pre-operative assessment inside theatre suite (includes emergency cases where doctor does not travel) (includes the interpretation of an ECG and/or lung function test).
Emergency visit (may not be charged together with any first or subsequent consultation item).
0104 Emergency attendance where doctor does not travel (all hours) (not applicable to facilities offering 24 hour services) (For IOD patients only applicable during after-hour periods - see general rule B).
0106 Emergency attendance at facilities offering 24 hour services (all hours) (For IOD patients only applicable during after-hour periods - see general rule B).
Where, in cases of emergency, a practitioner was called and has to travel to the patient at all hours.
0119 Doctor has to travel due to an emergency (all hours)*
* Footnote: Pre-anaesthetic assessment (all hours) (for IOD cases during after-hour periods - see general rule B) in cases of emergency. May be charged by an anaesthesiologist in cases of emergency where doctor has to travel (would replace items 0102 and 0105) irrespective of whether evaluation is followed by an anaesthetic or not.
0200 Cost of prostheses and/or internal fixation cost price + 20% with a maximum markup of R1 650.00.
0201 Cost of material: This item provides for a charge for material and special medicine used in treatment. Material to be charged for at cost price plus 35%. Charges for medicine used in treatment not to exceed the retail Ethical Price List.
a) External fixation apparatus (disposable): An amount equivalent to 25% of the purchase price of the apparatus may be charged where such apparatus is used.
b) External fixation apparatus (non-disposable): An amount equivalent to 20% of the purchase price of the apparatus may be charged where such apparatus is used.
c) In case of minor injuries requiring additional material (e.g. suturing material) payment shall be considered provided the claim is motivated.
d) Note
e) Medicine, bandages and other essential material for home-use by the patient must be obtained from a chemist on prescription or, if a chemist is not readily available, the practitioner may supply it from his own stock provided a relevant prescription is attached to his account. Charges for medicine used in treatment not to exceed the retail Ethical Price List.
0202 Setting of sterile tray: A fee of 10,00 clinical procedure units (R76.00) may be charged for the setting of a sterile tray where a sterile procedure is performed in the rooms. Cost of stitching material, if applicable, shall be charged for according to item 0201.
Refer to General Rule P
When in cases of emergency (refer to general rule P), a doctor has to travel more than 16 kilometres in total to visit an employee, travelling costs can be charged and shall be calculated as follows:
Consultation, visit or surgical fee: Plus:
5001 Cost of public transport and travelling time or item 5003.
5003 R4.00 per km for each kilometre in excess of 16 kilometres total travelled in own car: 19 km total = 3 x R4.00 = R12.00 (no travelling time).
Travelling time (Only applicable when public transport is used).
5005 Specialist: 18,00 clinical procedure units (R136.80) per hour or part thereof.
5007 General Practitioner: 12,00 clinical procedure units (R91.20) per hour or part thereof.
5009 After hours: Specialist: 27,00 clinical procedure units (R205.20) per hour or part thereof.
5011 After hours: General Practitioners: 18,00 clinical procedure units (R136.80) per hour or part thereof.
5013 Travelling fees are not payable to medical practitioners when they travel from a distance to assist at an operation on cases referred to surgeons by them.
5015 Travelling expenses may be charged from the medical practitioner's residence for calls received at night or during weekends in cases where travelling fees are allowed (For distances of 8 kilometres or more from starting point).
The unit values for the various groups and sections as from 1 January 2000 are as follows:
| Various Groups and Sections | VAT Exclusive | |||
|---|---|---|---|---|
| 1. | Consultation services | R 7.597 | ||
| 2. | Clinical procedure | R 7.597 | ||
| 3. | Anaesthetists | R 35.524 | ||
| 4. | Radiology | R 7.811 | ||
| 5. | Radiation Oncology | R 8.239 | ||
| 6. | Ultrasound | R 7.490 | ||
| 7. | Computed tomography | R 7.490 | ||
| 8. | Clinical Pathology | R 7.490 | ||
| 9. | Anatomical Pathology | R 7.811 |
The VAT inclusive amounts are calculated at 14% and not 13% as the previous years.
M/W 0046 Where in the treatment of a specific fracture or dislocation (compound or closed) an initial procedure is followed within one month by an open reduction, internal fixation, external skeletal fixation or bone grafting on the same bone, the fee for the initial treatment of that fracture or dislocation shall be reduced by 50%. Please note: This reduction does not include the assistant's fee or the after-hours levy where applicable. After one month, a full fee as for the initial treatment, is applicable.
M/W 0047 A fracture NOT requiring reduction shall be charged on a fee for service basis PROVIDED that the cumulative amount does NOT exceed the charges for a reduction.
M/W 0048 Where in the treatment of a fracture or dislocation an initial closed reductions is followed within one month by further closed reductions under general anaesthesia, the fee for such subsequent reduction will be 27,00 clinical procedure units (R205.20) (not including after-care).
M/W 0049 Except where otherwise specified, in cases of compound fractures, 77,00 clinical procedure units (R585.20) (specialists) and 51,00 clinical procedure units (R387.60) (general practitioners) are to be added to the fees for the fractures, including debridement.
M/W 0050 In cases of a compound fracture where a debridement is followed by internal fixation (excluding fixation with Kirschner wires and excluding fractures of hands and feet), the full amount according to either modifier 0049 or 0051 may be added to the fee for the procedure involved, plus half of the amount according to the second modifier (either 0049 or 0051 as applicable).
M/W 0051 Except where otherwise specified, in cases of fractures requiring open reduction, internal fixation, external skeletal fixation and/or bone grafting: Add 77,00 clinical procedure units (R585.20) (specialists) and 51,00 clinical procedure units (R387.60) (general practitioners).
M/W 0053 Fractures requiring percutaneous internal fixation [insertion and removal of fixatives (wires) in respect of fingers and toes included]: Add 32,00 clinical procedure units (R243.20) (specialists) and (general practitioners) add 21,00 clinical procedure units (R159.60).
M/W 0055 Dislocation requiring open reduction: Fee for the specific joint plus 77,00 clinical procedure units (R585.20) (specialists) and 51,00 clinical procedure units (R387.60) (general practitioners).
M/W 0057 In multiple procedures on feet, fees for the first foot are calculated according to modifier 0005. Calculate fees for the second foot in the same way, reduce the total to 50% and add to the total for the first foot.
M/W 0058 Revision operation for total joint replacement and immediate resubstitution (infected or non-infected): Per fee for total joint replacement plus 100%.
M/W 0005
(a) Modifier 0005 (multiple procedures/operations under the same anaesthetic) is not applicable if the following procedures are performed together:
- 1. Bone graft procedures and instrumentation are to be charged in addition to arthrodesis.
2. When vertebral procedures are performed by arthrodesis, bone grafts and instrumentation may be charged for in addition.
(b) Modifier 0005 (multiple procedures/operations under the same anaesthetic) would be applicable when arthrodesis is performed in addition to another procedure, e.g. osteotomy, laminectomy.
Note: Refer to General Rules Q, R, S and T.
RULES GOVERNING THIS SPECIFIC SECTION OF THE TARIFF
4.7.1 Tariff items for intensive care
Category 1 Cases requiring intensive monitoring (to include case where physiological instability is anticipated, e.g. diabetic pre-coma, asthma, gastrointestinal haemorrhage, etc.)
Category 2 Cases requiring active system support. (Where active specialised intervention is required in cases such as acute myocardial infarction, diabetic coma, head injury severe asthma, acute pancreatitis, flial chest, etc.)
Category 3 Cases with multiple organ failure. (May require multidisciplinary intervention.)
4.7.2 Procedures
1211 Cardio-respiratory resuscitation: Prolonged attendance in cases of emergency (not necessarily in ICU) 50,00 clinical procedure units (R380.00) per half hour or part thereof for the first hour per practitioner, thereafter 25,00 clinical procedure units (R190.00) per half hour up to a maximum of 150,00 clinical procedure units (R1140.00) per practitioner. Resuscitation fee includes all necessary additional procedures e.g. infusion, intubation, etc.
FF
(i) When a cystoscopy proceeds a related operation, modifier 0013 applies, i.e. cystoscopy followed by T U R prostatectomy.
(ii) When a cystoscopy proceeds an unrelated operation, modifier 0005 applies, e.g. cystoscopy for urinary tract infection followed by inguinal hernia repair.
No modifier applies to item 1949 when performed together with any of items 1951 to 1973.
Note: Rule - Prior approval must be obtained from the Commissioner before any treatment under this section is carried out. Where approval has been obtained, treatments must be limited to 12 sessions only, after which the patient must be referred back to the referring doctor for an evaluation and report to the Commissioner.
| Va | Visits at hospital or nursing home during a course of electro-convulsive treatment are justified and may be charged for besides fees for the procedure. | |
| Vb | Except where otherwise indicated, the duration of a medical psychotherapeutic session is set at 20 minutes or part thereof provided that such a part comprises 50% or more of the time of a session. This set duration is also applicable for psychiatric examination methods. |
Modifier Governing the Section Medical Psychotherapy
0079 If a first consultation proceeds into, or is immediately followed by a medical psychotherapeutic procedure, fees for the procedure shall be calculated at 24,00 clinical procedure units (R182.40) per 20 minute session or part thereof, provided that such a part comprises 50% or more of the time of a session.
M/W 0077
a) When two separate areas are treated simultaneously for totally different conditions, such treatment shall be regarded as two treatments for which separate fees may be charged. (Only applicable if services are provided by a specialist in physical medicine).
b) The number of treatments to a patient for which the Commissioner shall accept responsibility is limited to 20. If further treatments are necessary payment therefore must be arranged with the Commissioner.
Note: Payment for physiotherapy administered by a non-specialist medical practitioner who is already in charge of the general treatment of the employee concerned or by any partner, assistant or employee of such practitioner or any other practitioner or radiologist shall be made only with the express approval of the Commissioner: Application for approval to be made in advance if possible.
Diagnostic procedures
M/W 0001 For involuntarily scheduled after-hours emergency radiological services, the additional premium shall be 50% of the fee for the particular services (section 19.12 excluded). See general rule B.
For after-hours MR scans, a maximum levy of 100,00 radiological units (R780.00) is applicable.
M/W 0002 Item 38/0101 is applicable only where a radiologist is requested to give a written report on X-rays taken elsewhere and submitted to him.
M/W 0080 Multiple examinations: Full fees.
M/W 0081 Repeat examinations: No reduction.
M/W 0082 "+" means that this item is complementary to a preceding item and is therefore not subject to reduction.
M/W 0083 When a radiologist makes use of hospital equipment, only 66,67% (2/3) of the fee for the examination is chargeable.
Note in respect of fees payable when X-rays are taken by general practitioners:
(If the services of a radiologist are normally available, it is expected that they should be utilise. Should circumstances be unfavourable for obtaining such services at the time of the first consultation, the general practitioner may take the initial X-ray himself provided he submits a certificate to the effect that it was in the best interest of the employee for him to have taken the plates. Subsequent X-ray plates of the same injury, however, must be taken by a radiologist who has to submit the relevant reports in the normal manner).
When a general practitioner takes X-ray plates with his own equipment, if the services of a specialist radiologist are not available, he may claim at the prescribed fee.
If the radiographer of the hospital is not available and the general practitioner has to take the X-ray plates himself, he may claim at 50% of the prescribed fee for that service In that case, however, he should get confirmation of his X-ray findings in a report from the radiologist as soon as possible. The radiologist may then claim at one third of the prescribed fee for such service.
If a general practitioner orders an X-ray examination at a provincial hospital where there are no specialist radiological services available, he will not be paid for reading the plates as such a service is considered as an integral part of routine diagnosis, but if he is requested by the Commissioner to submit a written report on the case, he may claim at two thirds of the prescribed fee in respect thereof.
If a general practitioner has to take and read X-ray plates at a provincial hospital where the services of a radiographer and a specialist radiologist are not available he/she may claim 50% of the prescribed fee for such service.
M/W 0084 In the case of radiological items where films are used practitioners should adjust the fee upwards or downwards in accordance with changes in the price of films in comparison with January 1995; the calculation must be done on the basis that film costs comprise 10% of the monetary value of the unit.
M/W 0086 Vascular groups: "Film series" and "Introduction of Contrast Media" are complementary and together constitute a single examination: neither fee is therefore subject to increase in terms of Modifier 0080.
Please note: Modifier 0083 is not applicable to Section 19.8 of the tariff.
Rules applicable to vascular studies
(a) The machine fee (items 3536 to 3550) includes the cost of the following:
All runs (runs may not be billed for separately)
All film costs (modifier 0084 is not applicable)
All fluoroscopies (item 3601 does not apply)
All minor consumables (defined as any item other than catheters, guidewires, introducer sets, specialised catheters, balloon catheters, stents, embolic agents, drugs and contrast media)(b) The machine fee (items 3536 to 3550) may only be billed for as a once off fee per case per day by the owner of the equipment and is only applicable to radiology practices.
(c) If a procedure is performed by a non-radiologist together with a radiologist as a team, in a facility owned by the radiologist, each member of the team will fee at their respective full rates as per modifiers and the applicable codes.
(d) If a procedure is performed by a non-radiologist and a radiologist as a team, in a facility not owned by the radiologist, modifier 6301 and modifier 6302 applies.
M/W 6300 If a procedure lasts less than 30 minutes only 50% of the machine fees for items 3635 - 3550 will be allowed (specify time of procedure on account).
M/W 6301 If a procedure is performed by a radiologist in a facility not owned by himself, the fee will be reduced by 40% (i.e. 60% of the fee will be charged).
M/W 6302 When the procedure is performed by a non-radiologist, the fee will be reduced by 40% (i.e. 60% of the fee will be charged).
M/W 6303 When a procedure is performed entirely by a non-radiologist in a facility owned by a radiologist, the radiologist owning the facility may charge 55% of the procedure units used. Modifier 6302 applies to the non-radiologist performing the procedure.
M/W 6305 When multiple catheterisation procedures are used (items 3557, 3559, 3560, 3562) and an angiogram investigation is performed at each level, the unit value of each such multiple procedure will be reduced by 20,00 radiological units for each procedure after the initial catheterisation. The first catheterisation is charged at 100% of the unit value.
In the case of an aortagram for peripheral vascular disease the lower limbs are not added as well.
In the case of selective catheterisation of a branch of the aorta, the catheterisation and examination of the aorta are not added.
M/W 0089 The number of section of each examination and the matrix number must be specified. A full series of sections would be eight or more for brain examinations, 12 or more for chest examinations and 16 or more for abdomen examinations: Fees for examination on a matrix number of less than 250 shall be reduced by 50%.
Y Except where otherwise indicated, radiologists are entitled to claim for contrast material used.
Z No fee to be subject to more than one reduction.
M/W 0160 Aspiration of biopsy procedure performed under direct ultrasonic control by an ultrasonic aspiration biopsy transducer (Static Realtime) Fee for part examined plus 30% of the fee.
EE
(a) In case of a referral, the referring doctor must submit a letter of motivation to the radiologist or other practitioner doing the scan. A copy of the letter of motivation must be attached to the first account tendered to the employer.
(b) In case of a referral to a radiologist, no motivation should be required from the radiologist.
GG Images from all radiological, ultrasound and magnetic-resonance imaging procedures must be captured during every examination and a permanent record generated by means of film, paper, or magnetic media. A report of the examination, including the findings and diagnostic comment, must be written and stored for 5 years.
Note: In regard to multiple examinations see modifier 0080.
AA Procedures to exclude cost of Isotope.
M/W 0090 Radiologist's fee for participation in a team: 30,00 radiological units (R234.00) per half hour or part thereof for all interventional radiological procedures, excluding any pre- or post-operative angiography, catheterisation, CT-scanning, ultrasound scanning or X-ray procedures.
Please note: Modifier 0083 is not applicable to Section 19.8 of the tariff.
Rules applicable to vascular studies
(a) The machine fee (items 3536 to 3550) includes the cost of the following:
All runs (runs may not be billed for separately)
All film costs (modifier 0084 is not applicable)
All fluoroscopies (item 3601 does not apply)
All minor consumables (defined as any item other than catheters, guidewires, introducer sets, specialised catheters, balloon catheters, stents, embolic agents, drugs and contrast media)(b) The machine fee (items 3536 to 3550) may only be billed for as a once off fee per case per day by the owner of the equipment and is only applicable to radiology practices.
(c) If a procedure is performed by a non-radiologist together with a radiologist as a team, in a facility owned by the radiologist, each member of the team will fee at their respective full rates as per modifiers and the applicable codes.
(d) If a procedure is performed by a non-radiologist and a radiologist as a team, in a facility not owned by the radiologist, modifier 6301 and modifier 6302 applies.
M/W 6300 If a procedure lasts less than 30 minutes only 50% of the machine fees for items 3635 - 3550 will be allowed (specify time of procedure on account).
M/W 6301 If a procedure is performed by a radiologist in a facility not owned by himself, the fee will be reduced by 40% (i.e. 60% of the fee will be charged).
M/W 6302 When the procedure is performed by a non-radiologist, the fee will be reduced by 40% (i.e. 60% of the fee will be charged).
M/W 6303 When a procedure is performed entirely by a non-radiologist in a facility owned by a radiologist, the radiologist owning the facility may charge 55% of the procedure units used. Modifier 6302 applies to the non-radiologist performing the procedure.
M/W 6305 When multiple catheterisation procedures are used (items 3557, 3559, 3560, 3562) and an angiogram investigation is performed at each level, the unit value of each such multiple procedure will be reduced by 20,00 radiological units for each procedure after the initial catheterisation. The first catheterisation is charged at 100% of the unit value.
Note: In cases where a second Magnetic Resonance Imaging of the spine (items 6210, 6211, 6212 and 6213 refers) is deemed necessary, or a Magnetic Resonance Imaging of another anatomical region is requested, proper motivation must be submitted upon which the Commissioner will consider approval.
6100 In order to charge the full fee 500,00 radiological units (R3 900.00) for an examination of a specific single anatomical region, it should be performed with the applicable radio frequency coil including T1 and T2 weighted images on at least two planes.
6101 Where a limited series of a specific single anatomical region is performed (except bone tumour), e.g. a T2 weighted image of a bone for an occult stress fracture, not more than two-thirds (2/3) of the fee may be charged.
6102 All post-contrast studies (except bone tumour) to be charged at 50% of the fee.
M/W 0093 The fees for radiotherapy shall apply only where a specialist in radiotherapy uses his own apparatus.
BB The fees in this section do NOT include the cost of radium or isotopes.
M/W 0097 Where items under Pathology and Anatomical Pathology fall within the province of other Specialists or General Practitioners, then the fee is to be charged at two thirds of the pathologist's fee.
M/W 0099 For tests performed on a stat basis, an additional premium of 50% of the fee for the particular pathology service shall apply, with the following provisos:
Stat test requesting may only be done by the referring practitioner and not by the pathologist.
Specimens must be collected on a stat basis where applicable.
Test must be performed on a stat basis.
Documentation (or a copy thereof) relating to the request of the referring practitioner must be retained. This modifier will only apply during normal working hours and will never be used in combination with item 4547.
This modifier will only apply during normal working hours and will never be used in conjunction with item 4547.
Note: For fees for Histology and Cytology refer to items 4561 to 4593 under section 22: Anatomical Pathology.
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