Made to Measure

Anaesthetic billing is extremely complicated.  Therefore we have developed a special invoicing screen which allows you to input all the relevant information regarding the anaesthetic, and then generates the invoice lines for you.  This makes the difficult job of invoicing really easy, but it does mean that the tariff codes, modifiers, and different medical aid %’s must be set up correctly, so that these calculations can be performed accurately.  The web import for new rates will not include anaesthetists so you will need to update your own rates at the start of each year. Please follow these steps to ensure correct setup:

Units and Conversion Factor Types must be entered on the tariff code list

Every procedure code and modifier used in billing has been assigned a unit value and conversion factor types(CF) so that its value can be calculated every year by simply multiplying the number of units by a value that gets given to that CF.  The NHRPL Gazetted list of codes for 2009 remains the only place to find the codes with their units and CF’s.  How this excel sheet works is that the units and CF’s for specialists are in columns E&F; for GPs in columns J&K.  Anaesthetists will use these values for consultation and procedures that they do.  But when the procedure is something that they do the anaesthetic for, with the surgeon doing the actual procedure, then there is a CF (30) with a unit value in columns O&P that must be used (the surgeon will use the CF and units in columns E&F).  So that your rule is: If there are values in cols O&P use them, else use E&F for specialists or J&K for GP’s.  When setting up your codes initially, or getting ready to generate new prices for a new year, there is no need to type in any values on the tariff code – just put in the CF and units.

 In anaesthetics all the tariff codes fall into one of 3 different CFs.

1. CU – Consultation Units – CF=10  (or 130 for GP Anaesthetists)

These are the codes used for consultations.  The most important being 0151 the pre-op consultation code.   0147 is used as an automatic add on to 0151 for unscheduled operations.  Later consults are billed on the usual specialists’ 0190 code.  Note that most medical aids override the standard unit calculation for CU and have a set price for these items which we will deal with later.

2. CPU – Clinical Procedure Units CF = 20

These are the codes used for various procedures that do not have a separate anaesthetic CF and units(see 3 below).  Examples are codes for monitoring in ICU, putting in IV’s, catheters etc, doing nerve blocks, lumber punctures and all the normal Dr stuff. 

3. AU – Anaesthetic units CF = 30

These are the bulk of the codes that cover all the different procedures that get done under any anaesthetic, from removing a mole to transplanting a heart.  They are the ones where you will find the CPU for the surgeon in column E&F, but the AU you need are in columns O&P. Depending on your practice you may use few or many different codes.  We do not load them all in advance.  Please use the NRPL2010 for medical practitioners  provided on your setup CD to look them up as needed.  AU are also used on a number of special modifiers that are entered in the same way as codes.

 A list of compulsory codes that are used by the automatic invoicing and must be included in your tariff code list, is found in Appendix A.  It is important that the units are entered on these codes as indicated so that invoicing will be correct.

How to generate values for the different rates from CF and units

Now that the units and CF are entered on each tariff code, it is quick and easy to generate values in the different columns.  Please stick to our standards for cols 2,3,4  and 6 as below.  You can set the other columns to different MA plans or contracts you may have with funds that specify rates to charge.

Generate values by using the ‘Increase’ button on the tariff code screen and choosing ‘Convert from units for factor’.  For each col you will need to do each CF separately.  Sometimes there is no factor for consults so just type these few values in manually.

Note that you shouldn’t have to do col 2 since it will be in when we send you the software, but you can do it at any time just to ensure it has stayed correct over the years, as someone may have thought it necessary to increase it!  The other cols you will need to regenerate every year.

If you have contracted with a fund for a particular rate you may want to add extra columns for these special rates.   If this was a straight % on top of an existing rate, you could just put the % on the medical aid, or even on the patient.  But for Discovery the different CF’s get different % increases so you will need to generate them in their own column.  (Discovery will publish the new year’s CF values in December and note that tariffs must be accurately calculated to avoid Discovery paying the patient just because you are a few cents over the correct price)

Since anaesthetists use at most 3 consultation codes, 0151,0147 and 0190 – it is easy to enter theses values manually.  Do not adjust the consultation values in col 2 since they are used at different %’s by the different medical aids.

NB DISCOVERY only - After generating the values with the RCF as described you should still check them against the rates sent to you by Discovery as overcharging by even a few cents will result in the patient being paid instead of the practice.

Medical Aids need to point to which column to use

Each medical aid must point to the column it uses for billing and the % at which to bill it.  For Discovery and IOD this will always be 100% since the value will be one for the current year.  Other medical aids use the MedAid 2010 rate at their own specified %’s.  These %’s can be updated by clicking the import button on the medical aid screen which will fetch the latest %’s from our website.

If you are using special Discovery (or other) rates you can set up the plan as a separate medical aid to automate the medical aid’s pointer to its special column.  Eg create a new ‘Medical aid ‘ on code 125C for Discovery Classic and point it to use col 5 as set up above.

For less fussy medaids you may not have had to set up a special column but you can still create a separate plan and just use the % to up the value. Eg if you have an arrangement with Fedhealth at 150%, create code 160A and tell it to use the standard Medaid rate but increase the % by 50%

How to add a new procedure with its AU and get the values for the diff columns

When a procedure is used that was not on your tariff code list you will need to add it.  The easiest way to do this is to first get the units and CF from the gazetted list and put them in.  Then look for another procedure on your tariff codes list, with the same CF and units.  The simply copy the calculated values for each column into the new code.

Dentistry
All Dental Procedures are billed on code 1461.  Usually there is also a 0007 for use of own equipment, and then the materials used are billed under the general materials code 0201.  Note that this code requires a Nappi code to specify the particular item :- Eg 0201x1  798630019 Dormicum 5ml inj.  To bill the Nappi code you will need to have purchased the additional Nappi code module to plug into your Oribi software.

Assistant Fees
All 0029 lines for assistant are generated automatically by the special input form.

Comment codes
The following comment lines are generated automatically if selected .
0025  Recovery time rule
0035  7 Units rule
0036  80% rule
0020 Conscious Sedation

CONFIRM that generated items arecorrect

Please check that you are happy with the lines generated automatically.  Change any by double clicking to edit, or delete unwanteds. Made to Measure accepts NO LIABILITY for any errors in billing as a result of this automation, but we hope that it will make it will make your capture of these invoices easier and more accurate.

Add any extra codes, consumables,  ICU procedures etc afterwards, so they are added to the total invoice..

Appendix A Compulsory codes

The following codes are used by the automatic billing screen and must be available on the tariff code list:

*........not used inside anaesthetic form as its minutes must be entered separately

Appendix B Adding exceptions

A problem may arise when medical aids use the MedAid2010 column with their accumulated %’s for all the CPU and AU codes, but then publish a separate set rate for consultations.   Usually this is quite a bit higher that what it would be if you used the %.  That is why we have the exception button on the medical aid screen.  You can use it to override a calculated price with a set price.  Please be careful using this as it must be manually updated each year.