Made to Measure

Billing for surgical procedures is more complex than in general practice and is catered for by our Complex Billing Additional module – these notes are provided to give you some important guidelines.  In doubt please refer to the NRPL tariffs from BHF.

The tariff codes used fall into 2 main categories each of which has its own unit type with its own conversion factor:

1. Consultation Units (CU)  - conversion factor type 10 =  13.555 (MedAid2010)

eg:  0190 Consultation is set to 17 CU’s 

conversion factor type 616, 632etc are also sometimes used but they have the same value as type 10

Note that where non-Discovery Medaids have set consultation rates that do not conform to the 2010 + medaid % standard, then you will need to enter them as exception codes under the individual medical aid.

2. Clinical Procedure Units (CPU) - conversion factor type 20 =  8.395 (MedAid2010)

eg:  1675 Appendectomy is set to 160 CPU’s

(Note that Local Anaesthetic 0010 is billed in Anaesthetic units which are not available on your list of tariff codes since you always otherwise work with CPU.  Also the gazette is very confusing on how to bill this so it needs to be manually entered for now.  If you understand the gazette to read that there is a minimum of 11AU as on the 0036 code then set the value to 11 AU * 48.83(2010) = 537.10 as it appears unlikely that any procedure > 11AU would ever be done under local.)    

An account will typically include the following kinds of transaction lines:

            0190                           Consultation               consultation 

            1675                           Appendectomy                      procedure done

            0043                           Patient under 1yr                   modifier

            1743  - 0005              2^nd procedure with 0005 modifier reduces to 75% of fee

            0011   10 mins          Unscheduled theatre time    time

            0009                           Assistant DR SMITH 20% of above procedures

            0011   10 mins          Assistant unscheduled         time

CODES – Must be SET UP in TARIFF  list as follows

The codes should be entered with their units and Conversion factor type, so that it is easy and accurate to apply annual increases, and to generate different rates in the 9 available rates columns (see Tariff codes Help).  It is far better to use the increase option to generate the value column from the units and cft than to try to type in all the values.  The description can be entered as you like – Afrikaans only needed if you are using the bilingual option.

1.Codes modified by time:

When using these codes the minutes box must be filled in on the invoice form.

0011   Emergency Time  is set up on your tariff codes as 12 CPU

The program will then calculate the value as follows:

CPU  per ½ hour.  (Note that an assistant can bill this at the full rate as well as the surgeon)

1211   Resuscitation is set up on your tariff codes as 50 CPU with ‘Per minute billing’ checked
The program will calculate:
50 CPU for first ½ hour then 25 CPU for more ½ hours until max of 150 CPU

2.Modifiers that should be entered on their own line like codes 

a) Assistant Fees

0008   Assistant fees – specialist - is calculated as 33% of total fee

           This will call up the modifier automation screen so that you can select the procudes to include in the % calculation.  It can be set to a 0 value in the tariff code list.

 0009   Assistant fees – gp -  is calculated as 20% of total fee

This will call up the modifier automation screen  so that you can select the procudes to include in the % calculation.  Set up on your tariff codes as 36 CPU so that the minimum 36CPU can be applied to the calculation when applicable. (2010=R302.20)

b) Modifiers that are specified in a fixed number of CPU

0007   Use of own equipment  15 CPU. The value should be set in the tariff code list exactly as if it were an ordinary code.

Modifiers 0048 – 0055, 0070, 0075 etc are all specified in CPU and should be loaded and used as though they were ordinary tariff codes with values loaded. 

c) Modifiers that add a % onto a different code or codes.  

These could be entered into the modifier box of the main procedure invoice line, and would adjust the value accordingly.  However medical aids prefer to receive modifiers on their own line.  Therefore it is preferable to add the modifier on its own invoice line and then use the resultant modifier automation screen to select the procedure code/s to which the % should apply  so that the line value is calculated.  They can all be added to the tariff code list with a 0 value.

0004  Own rooms certain procedures adds 100%

0018   Patients with BMI >35  adds 50% 

0019   Neonates  adds 50

0058  Revision joint adds 100%

0066  Microsurgery fallopian adds 25% 

0067  Microsurgery Larynx adds 25% 

0069  Endoscopic nasal adds 10% 

0073  Cardiac catheter paed adds 100% 

0074  Endoscopic own equip adds 33% 

0078  vasogram adds 100%

3.Modifiers that must go on the same line as the procedure

These modifiers reduce the value of the procedure so cannot go on a separate line and must be entered in the modifier box so that the actual value of the procedure can be adjusted. They need not be on tariff code list as they are automatically available if the Surgery module has been purchased.

0005   This is entered or selected in the modifier box on the 2^nd and subsequent procedures so that the fee is reduced to 75 then 50 then 25%.  The % applied will be shown on the description line so that you can check that it is correct.  It can then be erased from there should you prefer not to print it.

0013  Endoscopic exam same op reduce to 50%

0046  Open reduction same bone within a month reduce to 50%

0057  2^nd foot reduces to 75%

0063  2 specialists reduces to 66.7%

0065  Spinal within a year reduce to 75%

4.  Consultation Codes 

0173   Hospital Consultation – Average Duration                                     17 CU

0174   Hospital Consultation – Moderate Duration                                   17 CU

0175   Hospital Consultation – Long/Complex Duration              17 CU

0190   Consultation – Average Duration –                                                 17 CU

0191   Consultation – Moderate Duration -                                                17 CU

0192   Consultation – Long/Complex Duration –                          17 CU

0130   Telephonic Consultation –                                                               12 CU

Plus any others eg 0146 0147 etc that you use

Note that you will probably have to enter these as exception codes as few medical aids still stick to the Consultation Units for Consults and have fixed their prices.

5.  Materials Codes

Materials are billed under 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.

We will inially enter some codes for you – please check that you are happy with the prices we have entered before using them.  As you add the codes that you use in your PR, you should enter the Units and CFT so that increases can be applied easily.

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 as follows:  (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 you use few consultation codes– it is easy to enter these values manually.  Do not adjust the consultation values in col 2 MedAid2010 since they are used at different %’s by the different medical aids.

If there is anything wrong and or missing from these notes – please let us know so that we can make the document useful to all our users.  Thank you