Scale of Fees > Annual Increase in Medical Tariffs for Medical Service Providers - 2022 > Prosthetics and Orthotics Gazette 2022

Section 73 Medical expenses

(1)

The Director-General or the employer individually liable or mutual association concerned, as the case may be, shall for a period of not more than two years from the date of an accident or the commencement of a disease referred to in section 65(1) pay the reasonable cost incurred by or on behalf of an employee in respect of medical aid necessitated by such accident or disease.

(2)

If, in the opinion of the Director-General, her medical aid in addition to that referred to in subsection (1) will reduce the disablement from which the employee is suffering, he may pay the cost incurred in respect of such further aid or direct the employer individually liable or the mutual association concerned, as the case may be, to pay it.

Section 42 Employee to submit to medical examination

An employee who claims compensation or to whom compensation has been paid or is payable shall when so required by the Director-General or the employer individually liable or mutual association concerned, as the case may be, after reasonable notice, submit himself at the time and place mentioned in the notice to an examination by the medical practitioner designated by the Director-general or the employer individually liable or mutual association concerned.

1.1	Each orthotic and prosthetic service provider should ensure that the service he/she provides is compatible with the general procurement guidelines issued by National Treasury.

1.2	The Compensation Fund will bear the reasonable cost for the issue of orthotic and prosthetic devices after an accident, provided that liability for the claim has been accepted and the service is prescribed by a medical practitioner and the prescribed guidelines are followed.

1.3	The published policy on the supply of orthotic and prosthetic devices and the tariff of fees will serve as a guideline to determine if any proposed service is reasonable and it will replace all existing tariff structures.

1.4

Pre-authorization by the Compensation Fund is required in all claims, even if the devices supplied are listed in the Government Gazette. It is the responsibility of the service provider to ensure that liability for the claim has been accepted by the Compensation Fund and that the service is reasonable and in line with the published policy and tariff. Amputees must be fitted with a prosthesis which is suitable for their environment and activity/load level.

1.5	Replacement of consumable items, refits and repairs must be motivated by the prosthetist and the medical practitioner. Requests must be reasonable and in line with the published policy and tariff.

1.6	The employee, assisted by a medical practitioner should complete the appropriate form when requesting replacement, re-fit or repair of any prosthetic/orthotic device. See Section 2 - Request For Prosthesis Services

1.7

The request for new equipment must be accompanied by a written report by the prosthetic practitioner indicating that the employee's functional level has been re-evaluated to take into account any physical or environmental changes encountered by the employee. See Sections 7 and 8 - Amputee Activity/Load Level Assessment Form

1.8	In exceptional circumstances, if the employment status and/or the functional level of an employee radically changes before a new prosthesis is due, a new prosthesis more suitable to the employment conditions will be considered by the Compensation Fund.

1.9

If an employee's employment status/functional level changes and a prosthesis in a higher category is requested, such higher functional level must be confirmed by the employer and a rehabilitation team comprising a medical practitioner, the prosthetist, a physiotherapist and/or an occupational therapist.

1.10	The service provider must obtain written authorisation for all quotation of prosthesis, refits, consumables and repairs. Accounts will not be payable for all quotation of prosthesis supplied without pre-authorisation for first amputees or any other prosthesis supplied to the employee.

1.11	The Compensation Fund will bear the reasonable cost of repairs to a prosthesis which has suffered from "fair" wear and tear after at least two years of normal use.

1.12	The Compensation Fund will not bear the cost of a prosthesis which is lost, broken, worn out or is otherwise unserviceable as a consequence of an employee's neglect or abuse.

1.13	The Commissioner will pay for the re -fit of the prosthesis strictly only where motivated and justifiable by the circumstances. See Section 4 - Guidelines for Refit

1.14	Replacement of some parts of a prosthesis (straps, socks, suspension sleeves etc) that may perish or become consumed through, reasonable usage be will paid for by the Compensation Fund in line with the policy guidelines. See Section 3 - Replacement Period Table.

1.15	The Compensation Fund reserves the right in terms of section 42 of the act to call for a second or independent opinion or evaluation of proposed orthotic/prosthetic services.

1.16

Any such report obtained by the Compensation Fund shall state whether the proposed orthotic/prosthetic service is appropriate for the diagnosis, functional level and environmental circumstances of the patient. The Compensation Fund reserves the right to use the information so obtained at his discretion and as is deemed appropriate.

1.17

The Commissioner is further entitled, pursuant to a complaint by the employee, to call for an independent report concerning any orthotic/prosthetic services that have been rendered. The Orthotists/prosthetist should strive to take all reasonable steps to attend to the legitimate complaints of an employee regarding services or assistive devices supplied. If it is found that defective or unsuitable devices have been supplied to an employee the Orthotists/prosthetist shall replace/repair/alter such devices at no additional cost to the Compensation Fund or the employee. The Compensation Fund reserves the right to decide on whether to maintain the said service provider on their data base of service providers or not.

1.18	The orthotic and/or prosthetic devices paid for by the Compensation Fund remains the property of the Compensation Fund. When an employee demises such devices should be returned to the Compensation Fund.

1.19	Each orthotic and prosthetic service provider should supply the fund with the quotation in order for the fluid to verify that the right items ordered and supplied to the employee are correct.

1.20	Each orthotic and prosthetic service provider should supply the fund with the rehabilitation report for all new amputees after fitting and supplying of a new prosthesis.

1.21	Orthotists/prosthetist and other service providers are required to quote a similar or better component using the same code.

1.22	Orthotists/prosthetist and other service providers should declare the use of the component and how it will benefit the employee.

1.23	The Compensation Fund retains the right to verify the product supplied to the employee should a need arise.

2.	Request for Orthotic/Prosthetic Services

The following details must accompany the request for prosthetic services:

2.1	Employee detail form See Section 6

2.2	Letter from the employee requesting orthotic/prosthetic services See Section 6

2.3	Motivation for services by orthotist/prosthetist

2.4	Motivation by the medical practitioner, if required by the guidelines

2.5	Amputee activity/load level assessment (for new prosthesis only) See Section 8

2.6	Refit report (for refit of prosthesis only) See Section 4

2.7	Quotation according to published tariffs See Section 9

3.	Replacement Periods of Medical Orthotic/Prosthetic Equipment

3.1

Prosthesis

Five years

3.2	Refit for prosthesis will be considered six months after fitting of new amputee with a prosthesis, and refit for old amputees can be considered after two and half years from the fitting of a new prosthesis: then to be motivated.

3.2	Silicone liners, sleeves, sockets	Two every three years
3.3	Gel liners, sleeves, sockets	Two every eighteen months
3.4	Prosthetic socks	Twelve per year
3.5	If worn with silicone or gel liners	Six per year
3.6	Prosthetic sheath	Twelve per year
3.7	If worn with silicone or gel liners	Six per year
3.8	Cosmetic stockings	Two pair per year
3.9	Cosmetic cover	One per year
3.10	Cosmetic skin	One every year
3.11	Calipers	Three years
3.12	Wheelchairs	Five year
3.13	Wheelchair cushions	Two years
3.14	Orthopaedic footwear	Two pair per year
3.15	Footwear modifications	Three modifications per year
3.16	Compression stockings	Four pairs every year
3.17	Off the shelf orthosis	Four every year
3.18	Custom made orthosis	Two every year

4.	Guidelines for Refit

This guideline covers prostheses that require refit of the socket after the initial issue. A full motivation with a report indicating the following details must be submitted:

4.1	Date of amputation

4.2	Date when the present prosthesis was fitted

4.3	Description of the prosthesis

4.4	Residual limb measurements when prosthesis was fitted

4.5	Symptoms indicating loss of fit

4.6	Diagnosis of loss of fit

4.7	Current residual limb measurements.

4.8	Number and thickness of prosthetic socks and worn by employee

4.9	Condition of prosthesis

4.10	The employee's current activity level

4 .11

An opinion as to the suitability of the specific prosthesis for the employee

5.	Functional Level

A determination of the medical necessity for certain components/additions to a prosthesis is based on the potential functional ability of the employee. Potential functional ability is defined as the reasonable expectation of the rehabilitation team including a medical practitioner, the prosthetist, a physiotherapist and/or an occupational therapist and the employee based on

•	past history including prosthetic use

•	current condition including the status of the residual limb and other medical factors

•	employment status

•	desire to ambulate

The clinical assessment of the employee's rehabilitation potential should be based on the following classification levels:

LEVEL 0:

Does not have the ability or potential ability to ambulate or transfer safely with or without assistance and a prosthesis will not enhance the mobility or quality of life

No prosthesis is recommended for amputees in this category.

LEVEL 1:

Has the ability or potential ability to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence - typically the limited and unlimited household ambulator

CATEGORY 1 components/prosthetics are recommended at this level. Amputees typically require significant stance phase security and minimal swing phase control.

LEVEL 2:

Has the ability or potential ability for ambulation and to traverse low level environmental barriers such as curbs, stairs and uneven surfaces - typically the limited community ambulator.

CATEGORY 2 components/prosthetics are recommended at this level. Amputees typically require moderate stance phase security and moderate swing phase control.

LEVEL 3:

Has the ability or potential ability for ambulation with variable cadence - typically the community ambulator that traverses most environmental barriers with vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion

CATEGORY 3 components/prosthetics are recommended at this level. Amputees typically require minimal stance phase security and maximal swing phase control.

LEVEL 4:

Has the ability or potential ability for prosthetic ambulation that exceeds basic ambulation skills exhibiting high impact, stress or energy levels. Daily activities require rigorous and repeated actions of high impact or stress such as lifting, jumping, climbing and walking long distances - typically the active adult ambulator.

In addition to CATEGORY 3 components, the employee requires components that will stand up to daily repeated high load and stress levels. Amputees typically require minimal stance phase security and maximal swing phase control.

UNLESS OTHERWISE STATED IN WRITING BY THE COMPENSATION FUND EMPLOYEES REQUIRING THIS LEVEL OF ORTHOTIC DEVICES SHALL BE GAINFULLY EMPLOYED.

6.	This form must be completed by the employee when orthotic/prosthetic services are requested.

COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993

Employee Details

Date: Claim number: _

Surname: ID Number: _

First names:

Postal address:

Tel (h) : Tel (w): _

Date of accident:

Employer at time of accident: __

Current employer: _

Type of orthotic/prosthetic service required: ____

Reason(s) why service is required:

Signature of employee

7.	This form must be completed by the orthotic/prosthetic practitioner

COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993

Employee Details

Date: Claim number: __

Surname: ID Number: __

First names: _

Postal address: _

Tel (h) : Tel (w): __

Date of accident: _

Employer at time of accident: ___

Current employer: __

RESIDUAL LIMB MEASUREMENTS

Amputation level: __

Side amputated:

Left

Right

Length of residual bone: Length of residual limb: ___

	Drawing of residual limb
Circumference measurements:
240 mm from distal end
200 mm from distal end
160 mm from distal end
120 mm from distal end
80 mm from distal end
40 mm from distal end

Signature Prosthetist

Date:

8.	Environment Activity and Load Levels

Patient: Claim number:

Home environment:

Suburban

Rural

Informal

Means of transport:

Private Vehicle

Public Transport

Pedestrian

Total distance travelled every day: ____________________________________

Work environment:
Commercial		Industrial		Agricultural		Mining

Job description at time of accident:

Current job description:

Describe actions of mobility while at work that may be affected by the typed of prosthesis fitted:

How often does patient wear prosthesis?

Every day

Occasionally

Seldom

How long does patient wear prosthesis every day?

All day

Most part of day

Less than half a day

Weight category:

Less than 75kg

Less than 100kg

Less than 125kg

More than 125kg

Mobility grade:
1. Indoor walker
2. Restricted outdoor walker
3. Unrestricted outdoor walker
4. Unrestricted outdoor walker with high impact levels

Remarks

Signature:

Prosthetist: Date:

9.	PROSTHETIC QUOTATION:

Patient: Claim number:

Amputation level:

Prosthetic Category:

	Code	Description	Amount excl VAT
Prosthesis
Foot
Ankle
Knee
Suspension:



Other:

Remarks:

Signed: Signed

Prosthetist Employee

Print name: Print name:

Date: Date:

10. CONFIRMATION OF RECEIPT OF ARTIFICIAL LIMB AND/OR OTHER ACCESSORIES

Claim number

1.	Confirmation of manufacture/supply by orthotic/prosthetic practitioner:

This serves to confirm that I have manufactured and supplied the following for the above mentioned employee, as per approval from the office of the Compensation Fund dated

Service provider:

Practice number:

Signature:

Date:

2.	Confirmation of receipt by employee:

I confirm that I have received the correct prosthesis and/or accessories and I am satisfied that it is in good working condition, to the value of R

Name:

Signature:

Date:

Telephone number:

3.	Confirmation of receipt of prosthesis by the provincial case manager:

Name:

Signature:

Date:

This form should be completed and submitted to the Compensation Fund by the orthotic/prosthetic service provider for payment with the account, a copy of the initial quotation and the letter of approval from the Compensation Fund.

Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)

Scale of Fees

Annual Increase in Medical Tariffs for Medical Service Providers - 2022

Prosthetics and Orthotics Gazette 2022

Orthotic & Prosthetic Supply Protocol