MODIFIER DESCRIPTIONS AND STANDARDS

Addition Modifier (AM)

This modifier will add a value by using a percentage value or a unit value to a procedure code. The modifier should be quoted on a separate line with its own value instead of adding its value to the code.

Compound Modifiers (CM)

The modifier should be quoted on a separate line with its own value at the end of the invoice instead of adding its value to the code. It should be indicated on each procedure code where the modifier is applicable

Reduction Modifiers (RM)

This modifier reduces the value of a procedure code/s by using a percentage or unit value. It should be quoted on the procedure codes where the modifier is applicable.

Information Modifier (IM)

Information Modifier (IM)

Modifier

Description

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

2 967.00

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

425.55

15

425.55

4.76

135.04

4.76

135.04

0008

Specialist surgeon assistant: The units of the procedure(s) for a specialist surgeon acting as assistant surgeon in procedures of specialised nature, is 40% of the units for the procedure(s) performed by specialist surgeon.

0009

Assistant: The units for an assistant are 20% of the units of that of a specialist surgeon, with a minimum of 36.00 clinical procedure units. The minimum units payable may not be less than 36.00 clinical procedures units.

36

1 021.32

36

1 021.32

0010

Local anaesthetic:

31

879.47

31

879.47

50

1 418.50

50

1 418.50

0011

Theatre procedures for emergency surgery: Any bona fide, justifiable emergency procedure (all hours) undertaken in an operating theatre and/or in another setting in lieu of an operating theatre, will attract 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 in respect of patients on scheduled lists.

(Definition: A medical emergency is any condition where death or irreparable harm to the patient will result if there are undue delays in receiving appropriate medical treatment)

12

340.44

12

340.44

12

340.44

0013

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

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 as part of a planned series of 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 IN THIS GUIDE TO TARIFFS

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[refer to modifier 0027 for more than one procedure under the same anaesthetic] and the time units (calculated according to the formula in modifier0023) 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 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 per 15 minute period or part thereof after the first hour.

2

265.12

2

265.12

0024

Pre-operative assessment not followed by a procedure: If a preoperative assessment 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.

3

397.68

3

397.68

0025

Calculation of anaesthesia time: Anaesthesia time is calculated from the time that the anaesthesiologist/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 it is required by the scope of the anaesthesia, an assistant anaesthesiologist may be employed. The units for the assistant anaesthesiologist/anaesthetist shall be calculated on the same basis as in the case where a general practitioner administered the anaesthesia.

0031

Intravenous infusion and transfusions: Treatment with intravenous drips and transfusions rendered either prior to, or during actual theatre or operating time, is considered part of the normal treatment in administering an anaesthetic.

0032

Patients in the prone position: Anaesthesia administered to patients in the prone position shall carry a minimum of 5.00 basic anaesthetic units. When the basic anaesthetic units for the procedure are 3.00, one additional anaesthetic unit should be added. If the basic anaesthetic units for the procedure are 5.00 or more, no additional units should be added.

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 0036: Anaesthetic administered by a general practitioner.

2

265.12

2

265.12

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  should be added. If the basic anaesthetic units for the procedure are 4.00 or more, no extra units should be added.

1

132.56

1

132.56

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 comprising basic units, time units and the appropriate modifiers.

TO

4

7

530.24

927.92

4

7

530.24

927.92

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. 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

927.92

7

927.92

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

397.68

3

397.68

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

530.24

4

530.24

0039

Deliberate control of blood pressure: All cases up to one hour: Add 3.00 anaesthetic units, thereafter add 1 (one) additional anaesthetic unit per quarter hour (15 mins) or part thereof (PLEASE INDICATE THE TIME IN MINUTES).

3

397.68

3

397.68

0041

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

+

1

3

132,56

397.68

1

3

132,56

397.68

0042

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

3

397.68

3

397.68

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

132.56

1

132.56

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

265.12

2

265.12

5443

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

3

397.68

3

397.68

5444

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

4

530.24

4

530.24

5445

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

5

662.80

5

662.80

5448

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

8

1060.48

8

1060.48

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

2 127.75

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 50%. 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

765.99

27

765.99

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

2 184.49

77

2 184.49

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

2 184.49

77

2 184.49

0052

Except where otherwise specified, fracture (traumatic or surgical, ie. osteotomy) requiring open reduction and/or internal fixation, external skeletal fixation and/or bone grafting (excluding fixation with Kirschner wires (refer to modifier 0053), as well as long bone or pelvis fracture/osteotomy (refer to modifier 0051) for specialist and general practitioners for HAND or FOOT fracture/osteotomy: Add to the appropriate procedure code

81.1

2 300.81

81.1

2 300.81

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

907.84

32

907.84

0055

Dislocation requiring open reduction: Units for the specific joint plus 77.00 clinical procedure units for specialists and general practitioners.

77

2 184.49

77

2 184.49

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 re-substitution (infected or non-infected): Units as for the procedure(s) + 100% of the units as for the total revision procedure (the units for modifier 0058 equals 100% of the procedure(s) performed plus appropriate modifiers)

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 units for the relevant part of the operation performed by him/her. Each surgeon may be remunerated as an assistant for the procedures performed by the other surgeon, at general practitioner units (refer to modifier 0009)

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

1 276.65

45

1 276.65

MODIFIER GOVERNING FEES FOR ENDOSCOPIC 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.

0075

Endoscopic procedures performed in own procedure room:

21

595.77

21

595.77

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

0080

Multiple examinations: Full Fee

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.

2.

0084

Charging for films and thermal paper by non-radiologists: In the case of radiological services rendered by non-radiologists where films, thermal paper or magnetic media are used, these media is charged for according to the film price of 2007, 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 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