PLEASE NOTE: The interpretations/comments as published in the SAMA Medical Doctors' Coding Manual (MDCM) must also be adhered to when rendering health care services under the Compensation for Occupational Injuries and Diseases Act, 1993.
| A. | Consultations: Definitions |
| (a) | New and established patients: A consultation/visit refers to a clinical situation where a medical practitioner personally obtains a patient's medical history, performs an appropriate clinical examination and, if indicated, administers treatment, prescribes or assists with advice. These services must be face-to-face with the patient and excludes the time spent doing special investigations which receives additional remuneration. |
| (b) | Subsequent visits: Refers to a voluntarily scheduled visit performed within four (4) months after the first visit. It may imply taking down a medical history and/or a clinical examination and/or prescribing or administering of treatment and/or counselling. |
| (c) | Hospital visits: Where a procedure or operation was performed, hospital visits are regarded as part of the normal after care and no fees may be levied (unless otherwise indicated). Where no procedure or operation was carried out, fees may be charged for hospital visits according to the appropriate hospital or inpatient follow-up visit code. |
| B. | Normal hours and after hours: Normal working hours comprise the periods 08:00 to 17:00 on Mondays to Fridays, 08:00 to 13:00 on Saturdays, and 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 work performed on these 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. Please note: Items 0146 and 0147 (emergency consultations) as well as modifier 0011 (emergency theatre procedures) are only applicable in the after hours period). |
| C. | Comparable services: The fee that may be charged in respect of the rendering of a service not listed in this tariff of fees or in the SAMA guideline, shall be based on the fee in respect of a comparable service. For procedures/services not in this tariff of fees but in the SAMA guideline, item 6999 (unlisted procedure or service code), should be used with the SAMA code. Motivation for the use of a comparable item must be provided. Note: Rule C and item 6999 may not be used for comparable pathology services (sections 21, 22 and 23). |
| D. | Cancellation of appointments: Unless timely steps are taken to cancel an appointment for a consultation the relevant consultation fee may be charged. In the case of an injured employee, the relevant consultation fee is 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. If a patient has not turned up for a procedure, each member of the surgical team is entitled to charge for a visit at or away from doctor's rooms as the case may be. |
| E. | Pre-operative visits: The appropriate fee may be charged for all pre-operative visits with the exception of a routine pre-operative visit at the hospital, as that routine pre-operative visit is included in the global surgical fee for the procedure. |
| F. | Administering of injections and/or infusions: Where applicable, fees for administering injections and/or infusions may only be charged when done by the practitioner him-/herself. |
| (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 the service to be rendered 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 Compensation Fund may be charged. |
| (d) | Normal aftercare refers to uncomplicated post-operative period not requiring any further surgical incision. |
| (e) | Abnormal aftercare refers to post-operative complications and treatment not requiring any further incisions and will be considered for payment. |
| H. | Removal of lesions: Items involving removal of lesions include follow-up treatment for four months. |
| I. | Pathological investigations performed by clinicians: Fees for all pathological investigations performed by members of other disciplines (where permissible) - refer to modifier 0097: Items that resort under Clinical and Anatomical Pathology: See section for Pathology. |
| J. | Disproportionately low fees: In exceptional cases where the 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. | Services of a specialist, upon referral: 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 referral letter that the patient was injured in an "accident' and this shall also apply in respect of specimens sent to pathologists. |
| L. | Procedures performed at time of visits: If a procedure is performed at the time of a consultation/visit, the fee for the visit PLUS the fee for the procedure is charged. |
| M. | Surgical procedure planned to be performed later: In cases where, during a consultation/visit a surgical procedure is planned to be performed at a later occasion, a visit may not be charged for again, at such a later occasion. |
| N. | Rendering of accounts for occupational injuries and diseases |
| (a) | "Per consultation": 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/visit performed at the time the condition is brought to the doctor's attention. |
| (b) | Where a fee for a service is prescribed in this guideline, the medical practitioner shall not be entitled to payment calculated on a basis of the number of visits or examinations made where such calculation would result in the prescribed fee being exceeded. |
| (c) | The number of consultations/visits must be in direct relation to the seriousness of the injury and should more than 20 visits be necessary, the Compensation Fund must be furnished with a detailed motivation. |
| (d) | A single fee for a consultation/visit shall be paid to a medical practitioner for the once-off treatment of an injured employee who thereafter passes into the permanent care of another medical practitioner, not a partner or assistant of the first. The responsibility of furnishing the First Medical Report in such a case rests with the second practitioner. |
| O. | Costly or prolonged medical services or procedures: |
| (a) | An employee should be hospitalized only when and for the length of period that his condition justifies full time medical assistance. |
| (b) | Occupational therapy/Physiotherapy: The same principals as set out in modifier 0077: Two areas treated simultaneously for totally different conditions, will apply when an employee is referred to a therapist. |
| (c) | In case of costly or prolonged medical services or procedures the medical practitioner shall first ascertain in writing from the Compensation Fund if liability is accepted for such treatment. |
| (a) | Where, in cases of emergency, a practitioner was called out from his residence or rooms to a patient's home or the hospital, traveling fees can be charged according to the section on travelling expenses (section IV) if the practitioner had to travel more than 16 kilometres in total. |
| (b) | If more than one patient is attended to during the course of a trip, the full travelling expenses must be divided between the relevant patients. |
| (c) | A practitioner is not entitled to charge for any traveling expenses or travelling time to his rooms. |
| (d) | Where a practitioner's residence is more than 8 kilometres away from a hospital, no travelling fees may be charged for services rendered at such a hospital, 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:
RULES GOVERNING THIS SPECIFIC SECTION OF THE TARIFF CODE
| Q. | Intensive care/High care: Units in respect of item codes 1204 to 1210 (Categories 1 to 3) EXCLUDE the following: |
| (a) | Anaesthetic and/or surgical fees for any condition or procedure, as well as a first consultation/visit fee for the initial assessment of the patient, while the daily intensive care/high care fee covers the daily care in the intensive care/high care unit. |
| (b) | Cost of any drugs and/or materials. |
| (c) | Any other cost that may be incurred before, during or after the consultation/visit and/or the therapy. |
| (d) | Blood gases and chemistry tests, including arterial puncture to obtain specimens. |
| (e) | Procedural item codes 1202 and 1212 to 1221, |
but INCLUDE the following:
| (f) | Performing and interpreting of a resting ECG. |
| (g) | Interpretation of blood gases, chemistry tests and x-rays. |
| (h) | Intravenous treatment (item codes 0206 and 0207). |
| R. | Multiple organ failure: Units for item codes 1208, 1209 and 1210 (Category 3: Cases with multiple organ failure) include item 1211: Cardio-respiratory resuscitation. |
| S. | Ventilation: Units for item codes 1212, 1213 and 1214 (ventilation) include the following: |
| (a) | Measurement of minute volume, vital capacity, time- and vital capacity studies. |
| (b) | Testing and connecting the machine. |
| (c) | Setting up and coupling patient to machine: setting machine, synchronising patient with machine. |
| (d) | Instruction to nursing staff. |
| (e) | All subsequent visits for the first 24 hours. |
| T. | Ventilation (item codes 1212 to 1214) does not form part of normal post-operative care, but may not be added to item code 1204: Category 1: Cases requiring intensive monitoring. |
RULES GOVERNING THE SECTION RADIOLOGY: MAGNETIC RESONANCE IMAGING
| NOTE | In the event of Complex medical cases (Poly-trauma, Traumatic Brain injury, Spinal injuries, etc.), the first Radiological investigations(e.g MRI, CT scan, Ultrasound and Angiography), Authorisation will not be required provided there was a valid indication. |
All second and Subsequent specialised Radiological investigations for Complex medical cases,will need a pre-authorisation.
Non-Complex medical cases/elective cases will need pre-authorisation for all specialised radiological investigations.
| (a) | Complete Annexure A and Annexure B, submit report of the investigation and an invoice. |
| (b) | Item code 6270 - Proper motivation must be submitted upon which the Compensation Fund will consider approval for payment.(Remove) |
RULES GOVERNING THE SECTION MEDICAL PSYCHOTHERAPY
Note:
| (a) | Prior approval must be obtained from the Compensation Fund before any treatment resorting under this section is carried out. |
| (b) | Where approval has been obtained, treatment 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 Compensation Fund. |
| Va. | Electro-convulsive treatment: Visits at hospital or nursing home during a course of electro-convulsive treatment are justified and may be charged for in addition to the fees for the procedure. |
| Vb. | When adding psychotherapy items to a first or follow-up consultation item, the clinician must ensure that the time stipulated in the psychotherapy items are adhered to (i.e. item 2957 - minimum 10 minutes, item 2974 - minimum 30 minutes. and item 2975 - minimum 50 minutes). |
RULES GOVERNING THE SECTION RADIOLOGY
| Z. | No fee to is subject to more than one reduction. |
RULE GOVERNING THE SUBSECTION ON DIAGNOSTIC PROCEDURES REQUIRING THE USE OF RADIO-ISOTOPES
| AA. | Procedures exclude the cost of isotope used. |
RULE GOVERNING THE SECTION RADIATION ONCOLOGY
| BB. | The units in the radiation oncology section do NOT include the cost of radium or isotopes. |
RULE GOVERNING ULTRASOUND EXAMINATIONS
EE.
| (a) | In case of a referral, the referring doctor must submit a letter of motivation to the radiologist or other practitioner performing the scan. A copy of the letter of motivation must be attached to the first account rendered to the Compensation Fund by the radiologist. |
| (b) | In case of a referral to a Radiologist, no motivation is required from the radiologist himself. |
RULES GOVERNING THE SECTION URINARY SYSTEM
FF.
| (a) | When a cystoscopy precedes a related operation, modifier 0013: Endoscopic examination done at an operation, applies, e.g. cystoscopy followed by transuretral (T U R) prostatectomy. |
| (b) | When a cystoscopy preceeds an unrelated operation, modifier 0005: Multiple procedures/operations under the same anaesthetic, applies, e.g. cystoscopy for urinary tract infection followed by inguinal hernia repair. |
| (c) | No modifier applies to item code 1949: Cystoscopy, when performed together with any of item codes 1951 to 1973. |
RULE GOVERNING THE SECTION RADIOLOGY
| GG. | Capturing and recording of examinations: 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 five years. |
