Specialist

General Practitioner

Anaesthetic

U/E

R

U/E

R

U/E

RT/M

MODIFIER GOVERNING THE RADIOLOGY AND RADIATION ONCOLOGY SECTIONS OF THE TARIFF CODES

0001

Emergency or unscheduled radiological services: For emergency or unscheduled radiological services (Refer to rule B) the additional fee shall be 50% of the fee for the particular service (section 19. 12: Portable unit examinations excluded).Emergency and unscheduled MR scans, a maximum levy of 100.00 Radiological units is applicable.

100

100

1,719.00

MODIFIER GOVERNING A RADIOLOGIST REQUESTED TO PROVIDE A REPORT ON X-RAYS

0002

Written report on X-rays: The lowest level item code for a new patient (consulting rooms) consultation is applicable only when a radiologist is requested to provide a written report on X-rays taken elsewhere and submitted to him. The above mentioned item code and the lowest level item code for an initial hospital consultation are not to be utilised for the routine reporting on X-rays taken elsewhere.

0005

Multiple therapeutic procedures/operations under the same anaesthetic:

APPLICATION OF MODIFIER 0005 IN CASES WHERE BONE GRAFT PROCEDURES AND INSTRUMENTATION ARE PERFORMED IN COMBINATION WITH ARTHRODESIS (FUSION)

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

15

246.60

15

246.60

0008

Specialist surgeon assistant: Where a procedure REQUIRES a registered specialist surgeon assistant, the tariff is 33,33% (1/3) of the fee for the specialist surgeon.

0009

Assistant: The fee for an assistant is 20% of the fee for a specialist surgeon, with a minimum of 36.00 clinical procedure units – the minimum fee payable may not be less than 36.00 clinical procedure units

36

591.84

0010

Local anaesthetic:

31

509.64

31

509.64

50

822.00

50

822.00

0011

Theatre procedures for emergency surgery: Any bona fide, justifiable emergency procedure, only applicable during after-hour periods - see general rule B, undertaken in an operating theatre, will justify the charging of an additional 12.00 clinical procedure units per half·hour or part thereof, of the operating time for all members of the surgical team. Modifier 0011 does not apply to patients on scheduled lists (PLEASE INDICATE TIME IN MINUTES).

12

197.28

12

197.28

0013

Endoscopic examinations done at operations: Where a related endoscopic examination is performed at an operation by the surgeon or the attending anaesthesiologist, only 50% of the fee for the endoscopic examination may be charged.

0014

Operations previously performed by other surgeons:

INJECTIONS, INFUSIONS AND

INHALATION SEDATION

MODIFIERS GOVERNING THIS

SPECIFIC SECTION OF THE

TARIFF CODE

0015

Intravenous infusions: Where intravenous infusions (including blood and blood cellular products) are administered as part of the after-treatment after an operation, no extra fees shall be charged as the after-treatment is included in the global fee for the procedure. Should the practitioner performing the operation prefer to request another practitioner to perform post-operative intravenous infusions, the practitioner himself (and not the Compensation Fund) shall be responsible for remunerating such practitioner for the infusions.

0017

Injections administered by practitioners: When desensitisation, intravenous, intramuscular or subcutaneous injections are administered by the practitioner him-/herself to patients who attend the consulting rooms, a first injection forms part of the consultation/visit and only all subsequent injections for the same condition should be charged according to item 0131 (not chargeable together with a consultation item).

MODIFIER GOVERNING SURGERY ON PERSONS WITH A BODY MASS INDEX (BMI) OF MORE THAN 35

0018

Surgical modifier for persons with a BMI of higher than 35 (calculated according to kg/m2 = weight in kilograms divided by height in metres squared): Fee for the procedure +50% of the fee for surgeons; 50% increase in anaesthetic time units for anaesthesiologists.

MODIFIERS GOVERNING THE ADMINISTRATION OF ANAESTHESIA FOR ALL THE PROCEDURES AND OPERATIONS INCLUDED

0021

Determination of anaesthetic fees: Anaesthetic fees are determined by adding the basic anaesthetic units (allocated to each procedure that can be performed under anaesthesia indicated in the anaesthetic column) and the time units (calculated according to the formula in modifier 0023) and the appropriate modifiers (see modifiers 0037-0044). In case of operative procedures on the musculo-skeletal system, open fractures and open reduction of fractures or dislocations, add units as laid down by modifiers 5441 to 5448.

0023

The basic anaesthetic units are laid down in the guide to tariffs and are reflected in the anaesthetic column. These basic anaesthetic units reflect the anaesthetic risk, the technical skill required of the anaesthesiologist/anaesthetist 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 anaesthesia. at 2 00 anaesthetic units is (R153.62) per 15 minute period or part thereof for the first hour. Should the duration of the anaesthesia be longer than one (1) hour the number of units shall be increased to 3.00 anaesthetic units (R230.43) per 15 minute period or part thereof after the first hour.

2

3

153.62

230.43

2

3

153.62

230.43

0024

Pre-operative assessment not followed by a procedure: If a preoperativeassessment of a patient by the anaesthesiologist/ anaesthetist is not followed by an operation, the assessment will be regarded as a consultation at a hospital or nursing home and thpriate hospital consultation fee should be charged.

0025

Calculation of anaesthesia time: Anaesthesia time is calculated from the time that the anaesthesiologistl anaesthetist 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/ anaesthetist is no longer required to give his/her personal professional attention to the patient, i.e. when the patient may, with reasonable safety, be placed under the customary post-operative nursing supervision. Where prolonged personal professional attention is necessary for the well-being and safety of a patient. the additional time spent can be charged for at the same rate as indicated above for anaesthesia time. The anaesthesiologist/ anaesthetist must record the exact anaesthesia time and the additional time spent supervising the patient on the account submitted.

0027

More than one procedure under the same anaesthesia: Where more than one operation is performed under the same anaesthesia, the basic anaesthetic units will be that of the operation with the highest number of units.

0029

Assistant anaesthesiologists: When rendered necessary by the scope of the anaesthesia, an assistant anaesthesiologist may be employed. The remuneration of the assistant anaesthesiologist shall be calculated on the same basis as in the case of a general practitioner administering the anaesthesia.

0031

Intravenous infusion and transfusions: Administering intravenous infusions and transfusions are considered to be a normal part of administering anaesthesia. No additional fees may be charged for such services when rendered either prior to, or during, actual theatre or operating time.

0032

Patients in the prone position: Anaesthesia administered to patients in the prone position shall carry a minimum of 4.00 basic anaesthetic units. When the basic anaesthetic units for the procedure are 3.00, one additional anaesthetic unit (R76.81) should be added. If the basic anaesthetic units for the procedure are 4.00 or more (R307.24), no additional units should be added.

1

4

76.81

307.24

4

76.81

307.24

0033

Participating in the general care of patients: When an anaesthesiologist/anaesthetist is required to participate in the general care of a patient during a surgical procedure, but does not administer the anaesthesia, such services may be remunerated at full anaesthetic rate, subject to the provisions or modifier 0035: Anaesthetic administered by a specialist anaesthesiologist/ anaesthetist and modifier 0038: Anaesthetic administered by a general practitioner.

0034

Head and neck procedures: All anaesthesia administered for diagnostic, surgical or X-ray procedures on the head and neck shall carry a minimum of 4.00 basic anaesthetic units. When the basic anaesthetic units for the procedure are 3.00, one extra anaesthetic unit (R76.81) should be added. If the basic anaesthetic units for the procedure are 4.00 or more (R307.24), no extra units should be added.

1

4

76.81

307.24

1

4

76.81

307.24

0035

Anaesthesia administered by an anaesthesiologist/ anaesthetist: No anaesthesia administered by an anaesthesiologist/ anaesthetist shall carry a total value of less than 7.00 anaesthetic units (R537 67) comprising basic units, time units and the appropriate modifiers.

7

537.67

7

537.67

0036

Anaesthesia administered by general practitioners: The anaesthetic units (basic units plus time units plus the appropriate modifiers) used to calculate the fee for anaesthesia administered by a general practitioner lasting one hour or less shall be the same as that for an anaesthesiologist. For anaesthesia lasting more than one hour, the units used to calculate the fee for anaesthesia administered by a general practitioner will be 4/5 (80%) of that applicable to a specialist anaesthesiologist, provided that no anaesthesia lasting longer than one hour shall carry a total value of less than 7.00 anaesthetic units (R537.67). Please note that the 4/5 (80%) principle will be applied to all anaesthesia administered by general practitioners with the provision that no anaesthesia totalling more than 11.00 units would be reduced to less than 11.00 units in total. The monetary value of the unit is the same for both anaesthesiologists/ anaesthetists.

7

537.67

7

537.67

Note: Modifying units may be added to the basic anaesthetic unit value according to the following modifiers (0037-0044, 5441-5448).

0037

Body hypothermia: Utilisation of total body hypothermia: Add 3.00 anaesthetic units

3

230.43

0038

Peri-operative blood salvage: Add 4.00 anaesthetic units for intra-operative blood salvage and 4.00 anaesthetic units for post-operative blood salvage.

4

307.24

0039

Deliberate control of blood pressure: All cases up to one hour: Add 3.00 anaesthetic units, thereafter add 1 (one) additional anaesthetic unit (R76.81) per quarter hour or part thereof (PLEASE INDICATE THE TIME IN MINUTES).

3

230.43

0041

Hyperbaric pressurisation: Utilisation of hyperbaric pressurisation: Add 3.00 anaesthetic units.

3

230.43

0042

Extracorporeal circulation: Utilisation of extracorporeal circulation: Add 3.00 anaesthetic units.

3

230.43

MUSCULO-SKELETAL SYSTEM:

MODIFIERS GOVERNING

ANAESTHETIC FEES FOR

ORTHOPAEDIC OPERATIONS

Modifiers 5441 to 5448

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

Add (1.00) anaesthetic unit, except where the procedure refers to the skeletal bones named in modifiers 5442 to 5448.

1

76.81

5442

Shoulder, scapula, clavicle, humerus, elbow joint, upper 1/3 tibia, knee joint, patella, mandible and tempero-mandibular joint:Add two (2.00) anaesthetic units.

2

153.62

5443

Maxillary and orbital bones: Add three (3.00) anaesthetic units.

3

230.43

5444

Shaft of femur: Add four (4.00) anaesthetic units.

4

307.24

5445

Spine (except coccyx), pelvis, hip, neck of femur:Add five (5.00) anaesthetic units.

5

384.05

5448

Sternum and/or ribs and musculo-skeletal procedures which involve an intra-thoracic approach: Add eight (8.00) anaesthetic units.

8

614.48

0045

Post-operative alleviation of pain:

MODIFIER GOVERNING FEES FOR AN

ANAESTHESIOLOGIST

UTILISING AN INTRA-AORTIC BALLOON PUMP (CARDIO-VASCULAR SYSTEM)

0100

Intra-aortic balloon pump: Where an anaesthesiologist would be responsible for operating an intra-aortic balloon pump, a fee of 75.00 clinical procedure units is applicable.

75

1 233.00

MUSCULO-SKELETAL SYSTEM:

MODIFIERS GOVERNING THIS SPECIFIC SECTION OF THE TARIFF

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 5O%. Please note: This reduction does not include the assistant's fee where applicable. After one month, the full fee for the initial treatment is applicable.

0047

A fracture NOT requiring reduction shall be charged on a fee per service basis PROVIDED that the cumulative amount does NOT exceed the fee 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 (not including aftercare).

27

443.88

27

443.88

0049

Except where otherwise specified, in cases of compound [open] fractures, 77.00 clinical units (specialists and general practitioners) are to be added to the units for the fractures including debridement [a fee for the debridement may not be charged for separately.

77

1,265.88

77

1,265.88

0050

In cases of a compound [open] fracture where a debridement is followed by internal fixation (excluding fixation with Kirschner wires, as well as fractures of hands and feet), the full amount according to either modifier 0049: Cases of compound [open] fractures, or modifier 0051: Fractures requiring reduction, internal fixation, external skeletal fixation and/or bone grafting, may be added to the fee for the procedure involved, plus half of the amount according to the second (either modifier 0049: Cases of compound [open] fractures or modifier 0051: Fractures requiring open reduction, internal fixation, external skeletal fixation and/or bone grafting, as applicable).

115.50

1,898.82

115.50

1,898.82

0051

Fractures requiring open reduction, internal fixation, external skeletal fixation and/or bone grafting: Specialists and general practitioners add 77.00 clinical procedure units.

77

1,265.88

77

1,265.88

0053

Fractures requiring percutaneous internal fixation insertion and removal of fixatives (wires) into fingers and toes]: Specialists and general practitioners add 32.00 clinical procedure units.

32

526.08

32

526.08

0055

Dislocation requiring open reduction: Units for the specific joint plus 77,00 clinical procedure units for specialists and general practitioners.

77

1,265.88

77

1,265.88

0057

Multiple procedures on feet: In multiple procedures on feet, fees for the first foot are calculated according to modifier 0005: Multiple procedures/ operations under the same anaesthetic. Calculate fees for the second foot in the same way, reduce the total by 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% of the fee.

MODIFIER GOVERNING COMBINED PROCEDURES ON THE SPINE

0061

Combined procedures on the spine: 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.

MODIFIERS GOVERNING THE SUBSECTION REPLANTATION SURGERY

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 a replantation procedure (or toe to thumb transfer) is unsuccessful, no further surgical fee is payable for amputation of the non-viable parts.

MODIFIER GOVERNING THE SECTION LARYNX

0067

Microsurgery of the larynx: Add 25% to the fee for the procedure performed. (For other operations requiring the use of an operation microscope, the fee shall include the use of the microscope, except where otherwise specified in the Tariff Guide).

MODIFIERS GOVERNING NASAL SURGERY

0069

When endoscopic instruments are used during intranasal surgery: Add 10% of the fee for the procedure performed. Only applicable to items 1025, 1027, 1030, 1033, 1035, 1036, 1039, 1047, 1054 and 1083.

MODIFIER GOVERNING OPEN PROCEDURE(S) WHEN PERFORMED THROUGH THORACOSCOPE

0070

Add 45.00 clinical procedure units to procedure(s) performed through a thoracoscope.

45

739.80

45

739.80

MODIFIER GOVERNING GASTROENTEROLOGY PROCEDURES

0074

Endoscopic procedures performed with own equipment: The basic procedure fee plus 33,33% (1/3) of that fee (plus ("+") codes excluded) will apply where endoscopic procedures are performed with own equipment.

MODIFIER GOVERNING FEES FOR ENDOSCOPIC PROCEDURES

0075

Endoscopic procedures performed in own procedure room: The fee plus 21.00 clinical procedure units will apply where endoscopic procedures are performed in own procedure rooms. This fee is chargeable by medical practitioners who own or rent the facility. Please note: Modifier 0075 is not applicable to any of the items for diagnostic procedures in the otorhino-laryngology sections of the tariff guide.

21

345.24

21

345.24

MODIFIER GOVERNING THE

SECTION ON PHYSICAL

TREATMENT

0077

Note: 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 should be embarked upon only with the express approval of the Commissioner. Such approval should be requested in advance.

MODIFIER GOVERNING THE

SECTION MEDICAL

PSYCHOTHERAPY

0079

When a first consultation/visit proceeds into, or is immediately followed by a medical psychotherapeutic procedure, fees for the procedure are calculated according to the appropriate individual psychotherapy code (Items 2957, 2974 or 2975): Individual psychotherapy (specify type).

MODIFIERS GOVERNING THE SECTION DIAGNOSTIC

RADIOLOGY

0001

Emergency or unscheduled radiological services: For emergency or unscheduled radiological services ( Refer to rule 8) the additional fee shall be 50% of the fee for the particular service (section 19.12: Portable unit examinations excluded). Emergency and unscheduled MR scans. A maximum levy of 100.00 Radiological units is applicable.

100

1,719.00

0002

Written report on X-rays: The lowest level item code for a new patient (consulting rooms) consultation is applicable only when a radiologist is requested to provide a written report on X-rays taken elsewhere and submitted to him. The above mentioned item code and the lowest level item code for an initial hospital consultation are not to be utilised for the routine reporting on X-rays taken elsewhere.

0080

Multiple examinations: Full Fee

0081

Repeat examinations: No reduction

0082

Plus("+") means that this item code is complementary to a preceding item code and is therefore not subject to reduction. The amount for plus("+") procedures must not be added to the amount for the definitive item and must appear on a separate line on the account.

0083

A reduction of 33.33% (1/3) in the fee will apply to radiological examinations as indicated in section 19: Radiology where hospital equipment is used.

Note in respect of fees payable when X-rays are taken by general practitioners:

If the services of a radiologist were normally available, it is expected that these should be utilised. Should circumstances be unfavourable for obtaining such services at the time of the first consultation, the general practitioner may take the initial X-ray photograph himself provided he submitted a report to the effect that it was in the best interest of the employee for him to have done so. Subsequent X-ray photographs of the same injury, however, must be taken by a radiologist who has to submit the relevant reports in the normal manner.

0084

Charging for films and thermal paper by non-radiologists: In the case of radiological services rendered by non-radiologists where film, thermal paper or magnetic media are used, these media is charged for according to the film price of 2002, as compiled by the Radiological Society of South Africa. (This list is available on request at [email protected]).

0085

Left side: Add to items 6500-6519 as appropriate when the left side is examined. The absence of the modifier indicates that the right side is examined.

MODIFIER GOVERNING

VASCULAR STUDIES

0086

Vascular groups: "Film series" and "Introduction of Contrast Media" are complementary and together constitute a single examination: neither fee is therefore subject to an increase in terms of modifier 0080: Multiple examinations.

PLEASE NOTE: Modifier 0083 is not applicable to Section 19.8 of the tariff.

Rules applicable to vascular studies:

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, anti-embolic agents, drugs and contrast media).

MODIFIERS GOVERNING VASCULAR STUDIES AND INTERVENTIONAL RADIOLOGY PROCEDURES

6300

If a procedure lasts less than 30 minutes only 50% of the machine fees for items 3536-3550 will be allowed (specify time of procedure on account).

6301

If a procedure is performed by a radiologist in a facility not owned by himself, the fee will be reduced by 40%"A. (i.e. 60% of the fee will be charged).

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).

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.

6305

When multiple catheterisation procedures are performed (item codes 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.

MODIFIERS GOVERNING

ULTRASONIC

INVESTIGATlONS

0160

Aspiration of biopsy procedure performed under direct ultrasonic control by an ultrasonic aspiration biopsy transducer (Static Real time): Fee for body part examined plus 30% of the units.

0165

Use of contrast during ultrasound study: add 6.00 ultrasound units.

6

97.44

MODIFIER GOVERNING

INTERVENTlONAL

RADIOLOGICAL PROCEDURES

0090

Radiologist's fee for participation in a team: 30.00 radiology units per ½ 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. (Only to be charged if radiologist is personally involved, and not for interpretation of images only).

30

515.70

30

515.70

MODIFIERS GOVERNING

MAGNETIC RESONANCE

IMAGING

6100

In order to charge the full fee (600.00 magnetic resonance units for an examination of a specific single anatomical region, the investigation should be performed with the applicable radio frequency coil including T1 and T2 weighted images on at least two planes.

600

10,314.00

6101

Where a limited series of a specific 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 - also applicable to all radiotherapy planning studies, per region.

6102

All post-contrast studies (except bone tumour) including perfusion studies should be charged at 50% of the fee.

Note: In cases where a Magnetic Resonance Imaging of any anatomical region is deemed necessary, written motivation must be submitted by the practitioner who requested the examination and attached to the account upon which the Compensation Fund will consider approval of payment.

MODIFIERS GOVERNING THE SECTION RADIATION

ONCOLOGY

0093

The fees for radiation oncology shall apply only where a specialist in radiation oncology uses his own apparatus

MODIFIERS GOVERNING THE SECTION PATHOLOGY

0097

Pathology tests performed by non-pathologists: Where item codes resorting under Clinical Pathology (section 21) and Anatomical Pathology (section 22) fall within the province of other specialists or general practitioners,the fee should be charged at two-thirds of the pathologists tariff.

0099

Stat basis tests: For tests performed on a stat basis, an additional fee of 50% of the fee for the particular pathology service shall apply, with the following provisos:

Stat tests may only be requested 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 code 4547: After-hours service.