General Rules

Rule

Rule Description

001

Unless timely steps are taken (at least two hours) to cancel an appointment for a consultation the relevant consultation fee shall be payable by the employee.

003

The service of an occupational therapist shall be available only on written referral, by a medical treating doctor.

The medical treating doctor must clearly indicate the reason for the referral, relationship to the original injury.

The referral may be on the service providers (Occupational therapy practice) letterhead, provided it is signed by the referring doctor.

004

Newly hospitalised patients will be allowed up to 20 sessions without pre-authorization.

If further treatment is necessary after a series of 20 treatment sessions for the same condition,the treating doctor must submit a motivation with treatment plan to the Compensation Fund for authorization.

005

Out-patient:Patients will be allowed up to 10 sessions without pre-authorization.

If further treatment is necessary after a series of 10 treatment sessions for the same condition, the treating doctor must submit a motivation with treatment plan to the Compensation Fund for authorization.

006

"After hours treatment" shall mean those emergency treatment sessions performed at night

between 18:00 and 07:00 on the following day or during weekends between 13:00 Saturday and 07:00 Monday.

Public holidays are treated as Sundays.

The fee for all treatment under this rule shall be the total fee for the treatment plus 50 percent.

This rule shall apply for all treatment administered in the practitioner's rooms,or at a hospital or private residence (only by arrangement when the patient's condition necessitates it).

Modifier 0006 must then be quoted after the appropriate tariff code to indicate that this rule is applicable.

008

The provision of aids or assistive devices shall be charged at cost.

Modifier 0008 must be quoted after the appropriate tariff code to show this rule is applicable.

009

Materials used in the construction of orthoses will be charged as per Annexure "A" for the applicable device and pressure garments will be charged as per Annexure "B" for the applicable garment.

Modifier 0009 must be quoted after the appropriate tariff code to show that this rule is applicable.

010

Materials used in treatment shall be charged at cost.

Modifier 0010 must be quoted after the appropriate tariff code to show that this rule is applicable.

011

When the Occupational Therapist performs treatment away from his/her premises conducting

work visit at the employer's premises.

The travelling costs more than 16 kilometres will be calculated at R4,84 per km for each kilometre travelled in own car e.g. 19 km total = 19X R4,84 = R91.96.

If more than one employee is attended to during the course of a trip, the full travelling expenses must be pro-rata between the relevant employees (the practitioner will charge for one trip).

Note: POEs to be attached :work visit attendance register, work visit report and google map intake from the practice to the destination.

014

Only one Evaluation Procedure code may be billed per treatment session and utilised as per the rule of the individual code

016

Occupational Therapists.Physiotherapists and Chiropractors may not provide simultaneous treatment at the same time on a day,but may treat the same patient. (Multidisciplinary goals must be considered and the best placed service provider to achieve the rehabilitation goal must address that specific goal).

020

The use of the work hardening codes must match the rehabilitation plan provided by the Occupational Therapist and should clearly indicate how the work hardening program will be included in their rehabilitation program and graded return to work plan.

The therapist may provide a maximum of 10 sessions of group work hardening intervention per patient, where a maximum of 5 patients are treated simultaneously in the same treatment area and each patient is set up with customised work simulation tasks.Each session to take place on a separate day and to be of duration of at least 120 minutes.

If more than 10 sessions are necessary the authorization must be requested from the Fund. Note: The Occupational therapist to add the confirmation of employment which must accompany the pre-authorization request for work hardening.

Modifiers

Modifier

Modifier Description

0017

Services rendered to hospital in-patients: Quote modifier 0017 on all invoices for services performed on hospital in-patients.

0018

Services rendered to out-patients: Quote modifier 0018 on all invoices for services performed on hospital outpatients.

0006

Emergency modifier: add 50% of the total fee for treatment.

Refer to Rule 006

0008

Aids or assistive devices should be charged at cost.

Refer to Rule 008

0009

Materials used for construction of orthoses or pressure garments should be charged as per Annexures "A and B" for the applicable device and pressure garments.

See Annexures "A and B" for non-standard products.

Refer to Rule 009

0010

Materials used in treatment should be charged at cost.

Refer to Rule 010

0011

Travelling cost according to CF agreed rates.

Refer to Rule 011.

0012

A detailed report of the work assessment with signatures of the employer and the injured worker shall be submitted to the Compensation Commissioner with the invoice.

1.

CONSULTATION TARIFF CODES

Code

Code Description

UNITS

RAND

66101

First consultation (5-15 min). Charged once.

60

795.15

66108

Follow-up consultation (15-30 min). May be charged twice only per week.

15

198.79

66109

Follow-up consultation (30-60 min). May be charged up to four times per week.

30

397.58

2.

EVALUATION PROCEDURES

Code

Code Description

UNITS

RAND

66201

Observation and screening. May be charged at every treatment session as clinically appropriate.

10

132.53

66203

Specific evaluation for a single aspect of dysfunction (Specify which aspect). May be charged once per week as clinically appropriate.

7.5

99.39

66205

Specific evaluation of dysfunction involving one part of the body for a specific functional problem (Specify part and aspects evaluated). May be charged once per week as clinically appropriate.

22.5

298.18

66207

Specific evaluation for dysfunction involving the whole body (Specify condition and which aspects evaluated). May be charged once per three months as clinically appropriate.

45

596.37

66209

Specific in depth evaluation of certain functions affecting the total person (Specify the aspect assessed). May be charged once per three months as clinically appropriate.

75

993.94

66211

Comprehensive in depth evaluation of the total person (Specify aspects assessed).

Tariff code 66211 cannot be charged together with tariff code 66136.

105

1391.52

66136

In depth evaluation of the total person to enable the vocational rehabilitation specialist to complete a comprehensive assessment of certain functions affecting the total person. (This code can only be requested by the Compensation Fund for Section 42 Case reviews).

Tariff code 66136 cannot be charged together with tariff code 66211.

218.15

2891.05

3.

MEASUREMENT FOR DESIGNING

Code

Code Description

UNITS

RAND

66213

Measurement for designing a static orthosis.

10

132.53

66215

Measurement for designing a dynamic orthosis

10

132.53

66217

Measurement for designing a pressure garment for one limb orthosis

10

132.53

66219

Measurement for designing a pressure garment for one hand orthosis

10

132.53

66221

Measurement for designing a pressure garment for the trunk orthosis

10

132.53

66223

Measurement for designing a pressure garment for the face (chin strap only)

10

132.53

66225

Measurement for designing a pressure garment for the face (full face mask) orthosis

10

132.53

The whole body or part thereof will be the sum total of the parts.

4.

PROCEDURES FOR THERAPY

Code

Code Description

UNITS

RAND

66301

Group treatment in a task-cantered activity, per patient (treatment time 60 minutes or more).

10

132.53

66303

Placement of a patient in an appropriate treatment situation requiring structuring the environment, adapting equipment and positioning the patient.

This does not require individual attention for the whole treatment session

20

265.05

66305

Groups directed to achieve common goals per person.

20

265.05

66307

Simultaneous treatment of two to four neuro - behavioural and stress related conditions or severe head injury patients,each with specific problems utilising individual activities, per patient (treatment time 90 minutes or more)

48

636.12

66308

Simultaneous treatment of two to four patients,each with specific problems utilising individual activities, per patient (treatment time 60 minutes or more)

30

397.58

5.

INDIVIDUAL AND UNDIVIDED ATTENTION DURING TREATMENT SESSIONS UTILISING SPECIFIC ACTIVITY OR TECHNIQUES IN AN INTEGRATED TREATMENT SESSION (TIME OF TREATMENT MUST BE SPECIFIED)

Code

Code Description

UNITS

RAND

66309

On level one (15 min)

12

159.03

66311

On level two (30 min)

24

318.06

66313

On level three (45 min)

36

477.09

66315

One level four (60 min)

48

636.12

66317

On level five (90 min)

72

954.19

66319

On level six (120 min)

96

1272.25

6.

PROCEDURES FOR WORK REHABILITATION

Code

Code Description

UNITS

RAND

66321

Work evaluation - This includes an assessment of the inherent demands of the job and the patient's ability to perform these.

A detailed report is not included in this code (charged for under 66325), but must be submitted with the referral from the medical practitioner.)

Tariff code 66321 cannot be charged together with tariff code 66211 or 66136.

80

1060.21

66323

Work Visit Evaluation of the job tasks by observing while the patient or  a colleague in the same role performs the job tasks. May include discussing possible adaptations to the process or the work station and making the necessary recommendations to enable a patient to return to work: Rule: A maximum of two work visits are allowed per patient. However, in extenuating circumstances,further motivation may be made to the Compensation Fund.

Tariff code 66323 cannot be charged with tariff code 66211or 66136.

40

530.10

66325

Reports - To be used only when reporting on work assessments. Use once per day and per claim only

22.14

293.41

66327

Work hardening.

Must include a graded return to work plan.

Refer to Rule 020.

80

1060.21

7.

PROCEDURES REQUIRED TO PROMOTE TREATMENT

Code

Code Description

UNITS

RAND

66401

Workplace assessment (Recommendation as regards to assistive device and environmental adaptations.)

Tariff coce 66401 can only be charged together with tariff codes 66211, 66321, 66323 and 66327.

15

198.79

8.

DESIGNING AND CONSTRUCTING A CUSTOM MADE ADAPTATION OR ASSISTIVE DEVICE, SPLINT OR SIMPLE PRESSURE GARMENT FOR TREATMENT IN TASK-CENTERED ACTIVITY (SPECIFY THE ADAPTATION, DEVICE, SPLINT OR PRESSURE GARMENT)

Code

Code Description

UNITS

RAND

66403

On level one

12

159.03

66405

On level two

24

318.06

66407

On level three

36

477.09

66409

On level four

48

636.12

66411

On level five

60

795.15

66413

On level six

72

954.19

66415

Designing and constructing a static orthosis

60

795.15

66417

Designing and constructing a dynamic orthosis

120

1590.31

9.

DESIGNING AND MAKING PRESSURE GARMENT

Code

Code Description

UNITS

RAND

66419

Per limb

60

795.15

66421

Face (chin strap only)

45

596.37

66423

Face (full face mask)

60

795.15

66425

Trunk

90

1192.73

66427

Per hand

90

1192.73

The whole body or part thereof will be the subtotal of the parts for the first garment and 75% of the fee for any additional garments on the same pattern

66431

Planning and preparing in depth home programme on a monthly basis.

90

1192.73