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.

Note: This modifier should follow a procedure code on a separate line.

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

Note: This modifier should follow a procedure code on a separate line.

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.

Note: This modifier should be quoted on the same line with procedure where applicable.

Information Modifier (IM)

This modifier provides additional information to a procedure code and carried no financial value.

Note: This modifier should be quoted on the same line with procedure where applicable.

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 CODING STRUCTURE

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

3 252.00

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

100% (full value) for the first or major procedure/operation,

75% for the second procedure/operation,

50% for the third procedure/operation,

25% for the fourth and subsequent procedure/operation,

This modifier does not apply to purely diagnostic procedures.

0006

IM:

Visiting specialists performing procedures: Where specialists visit smaller centres to perform procedures, fees for these particular procedures are exclusive of after-care. The referring practitioner will then be entitled to subsequent hospital visits for after-care. If the referring practitioner is not available, the specialist shall, on consultation with the patient, choose an appropriate locum tenens. Both the surgeon and the practitioner who handled the after-care, must in such instances quote Modifier 0006 with the particular items which they use.

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

AM:

15

466.50

15

466.50

NOTE:

Equipment is included in hospital fee and therefore modifier is not payable.

Medical Doctors to make payment arrangement with the hospital for using own equipemtn during theatre procedures.

0008

CM:

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

CM:

Assistant: The fee for an assistant is 20% of the fee for the 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

1 119.60

36

1 119.60

0010

Local anaesthetic:

0011

CM:

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.

(Note: 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

373.20

12

373.20

12

373.20

0013

RM:

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 charged.

0014

IM:

Operations previously performed by other surgeons:

INJECTIONS, INFUSIONS AND INHALATION SEDATION

MODIFIERS GOVERNING THIS SPECIFIC SECTION OF THE TARIFF CODE

0015

IM:

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

RM:

Injections administered by practitioners: When desensitisation, intravenous, intramuscular or subcutaneous injections are administered by the practitioner 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 at 7.50 consultative service units using modifier 0017 to reflect the amount. (not claimed 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 TARIFF STRUCTURE

0021

IM:

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 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

AM:

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

290.62

2

290.62

0024

IM:

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

435.93

3

435.93

0025

IM:

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

IM:

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

CM:

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

IM:

Intravenous infusion and transfusions: Administering intravenous infusions and transfusions are considered to 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

AM:

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.

2

290.62

2

290.62

0033

IM:

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 anaesthesiologist/anaesthetist and modifier 0036: Anaesthetic administered by a general practitioner.

2

290.62

2

290.62

0034

AM:

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

145.31

1

145.31

0035

AM:

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.

7

1 017.17

7

1 017.17

0036

AM:

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.

Note:

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

7

1 017.17

7

1 017.17

0037

AM:

Body hypothermia:

Utilisation of total body hypothermia: Add 3.00 anaesthetic units

3

435.93

3

435.93

0038

AM:

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

581.24

4

581.24

0039

AM:

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

435.93

3

435.93

0041

AM:

Hyperbaric pressurisation:

Utilisation of hyperbaric pressurisation: Add 3.00 anaesthetic units.

3

435.93

3

435.93

0042

AM:

Extracorporeal circulation:

Utilisation of extracorporeal circulation: Add 3.00 anaesthetic units.

3

435.93

3

435.93

MUSCULO-SKELETAL SYSTEM

MODIFIERS GOVERNING ANAESTHETIC FEES FOR ORTHOPAEDIC OPERATIONS

Modifiers 5441 to 5448

Note:

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

AM:

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

1

145.31

1

145.31

5442

AM:

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

Note:

Not appropriate where arthroscopy only is performed

2

275.72

2

275.72

5443

AM:

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

3

435.93

3

435.93

5444

AM:

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

4

581.24

4

581.24

5445

AM:

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

5

726.55

5

726.55

5448

AM:

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

8

1162.48

8

1162.48

MODIFIER GOVERNING FEES FOR AN ANAESTHESIOLOGIST UTILISING AN INTRA-AORTIC BALLOON PUMP (CARDIO-VASCULAR SYSTEM)

0100

AM:

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

2 332.50

MUSCULO-SKELETAL SYSTEM

MODIFIERS GOVERNING THIS SPECIFIC SECTION OF THE TARIFF

0046

RM:

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%.

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

IM:

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

AM:

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 after-care).

27

839.70

27

839.70

0049

AM:

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

2 394.70

77

2 394.70

0051

AM:

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

77

2 394.70

77

2 394.70

0052

AM:

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

2 522.21

81.1

2 522.21

0053

AM:

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

995.20

32

995.20

0055

AM:

Dislocation requiring open reduction:

Units for the specific joint plus 77.00 clinical procedure units for specialists and general practitioners.

77

2 394.70

77

2 394.70

0057

RM:

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.

The total units for the second foot are reduce the total by 50% and add to the total for the first foot.

0058

AM:

Revision operation for total joint replacement and immediate re-substitution (infected or non-infected): per fee for total joint replacement + 100% of the unit fee.

MODIFIER GOVERNING COMBINED PROCEDURES ON THE SPINE

0061

IM:

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

RM:

Where two specialists work together on a replantation procedure, each shall be entitled to two-thirds of the fee for the procedure.

0064

RM:

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

AM:

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

AM:

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

AM:

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

45

1 399.50

45

1 399.50

MODIFIER GOVERNING FEES FOR ENDOSCOPIC PROCEDURES

0074

AM:

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

AM:

Endoscopic procedures performed in own procedure room:

21

635.10

21

635.10

MODIFIER GOVERNING THE SECTION ON PHYSICAL TREATMENT

0077

IM:

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

IM:

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

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.

0080

Multiple examinations: Full Fee

0081

IM

Repeat examinations: Full Fee

0082

IM

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

0083

RM

A reduction of 33,33% (1/3) in the fee apply to radiological examinations as indicated in section 19: Radiology where hospital equipment is used.

NOTE:

Modifier 0083 is not applicable to Section 19.8 of the tariff

0084

IM

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

IM

Left side:

Add to items 6500-6519 as appropriate when the left side is examined.

NOTE:

The absence of the modifier indicates that the right side is examined.

MODIFIER GOVERNING VASCULAR STUDIES

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).

0086

IM

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.

6300

RM

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 Invoice).

6302

RM

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

RM

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

RM

When multiple catheterisation procedures are used (items 3557, 3559, 3560, 3562) and an angiogram investigation is performed at each level, the unit value of each multiple procedure will be reduced by 20.00 radiological units for each procedure after the initial catheterisation.

The first catheterisation is coded at 100% of the unit value.

MODIFIER GOVERNING INTERVENTIONAL RADIOLOGICAL PROCEDURE

MODIFIERS GOVERNING DIAGNOSTIC SERVICES

0091

IM

Diagnostic services rendered to outpatients: Quote Modifier 0091 on all accounts for diagnostic services (e.g. MRI, X-rays, pathology tests) performed on patients officially admitted to hospital or day clinic (refer to Rule XX)

0092

IM

Diagnostic services rendered to outpatients: Quote Modifier 0092 on all accounts for diagnostic services (e.g. MRI, X-rays, pathology tests) performed on patients NOT officially admitted to hospital or day clinic (could be within the confines of a hospital) (refer to Rule YY)

MODIFIERS GOVERNING THE RADIATION ONCOLOGY SECTION

0095

IM

Radiation materials: Exclusively for use where radiation materials supplied by the practice are used by clinical and radiation oncologists, modifier 0095 should be used to identify these materials.

A material code list with descriptions and guideline costs for these materials, maintained and updated on a regular basis, will be supplied by the Society of Clinical and Radiation Oncology.

This modifier is only chargeable by the practice responsible for the cost of this material and where the hospital did not charge therefore.

Please note that item 0201 should not be used for these materials.

MODIFIERS GOVERNING THE SECTION PATHOLOGY

0097

RM

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

MODIFIERS GOVERNING ULTRASOUND INVESTIGATIONS

0165

Use of contrast during ultrasound study: add 6.00 ultrasound units

MODIFIERS GOVERNING MAGNETIC RESONANCE IMAGING

6106

IM

Where a magnetic resonance angiography (MRA) of large vessels is performed as primary examination, 100% of the fee is applicable.

This modifier is only applicable if the series is performed by use of a recognised angiographic software package with reconstruction capability.

6107

RM

Where a magnetic resonance angiography (MRA) of the vessels is performed additional to an examination of a particular region, 50% of the fee is applicable for the angiography.

This modifier is only applicable if the series is performed by use of a recognised angiographic software package with reconstruction capability

6108

RM

Where only a gradient echo series is performed with a machine without a recognised angiographic software package with reconstruction ability, 20% of the full fee is applicable specifying that is is a "flow sensitive series".