Best Practice Guidelines: Healthcare Practice Management & POPIA Compliance Framework

Best Practice Guidelines: Healthcare Practice Management

POPIA Compliance Framework




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10. Billing: Roles & Purpose

10.3. Medical Codes & Rules

Understand your Medical Codes & Rules

Medical practitioners do not only have to diagnose and treat their patients, but they also have to spend large amounts of time managing the financial information related to the dispensing of medical supplies, use of the equipment and calculating the rates for different medical procedures. The range of medical procedures and routines that take place in the medical industry is extensive and the result is that the billing process can become quite complicated if you do not have an understanding of how codes and modifiers are used when issuing invoices.

What are codes and why do they exist?

Medical codes are essentially used to describe and categorise the types of services rendered or medicines used to treat patients and to calculate their invoices. When claims are submitted to medical aids, the codes and descriptions are used as references to validate fees and payments. Most codes consist of a code, description and an amount that is allowed to be charged for the different specialities.

What are modifiers?

Modifiers are codes that are used by certain medical practitioners in conjunction with their normal codes to modify or change the rate at which they charge patients during a consultation or procedures. For example, a practitioner may perform more than one procedure during consultation and use a modifier to adjust the second procedure’s amount. GoodX has built-in functionality to help you configure and manage these modifiers. Incorrect use of modifiers is considered fraud or non-compliance and can result in further audits and revenue loss.

Types of modifiers:

a. Addition modifier

A modifier that adds value, by using a percentage value or a unit value, to a procedure code. This modifier should be added to a separate line with its own value.

b. Compound modifier

Modifiers that must be posted on a separate line with its own value but must also be indicated on each procedure code's line where it is applied.

    c. Information modifier

    A modifier that serves to add additional information to procedure codes and has no financial value. This must be added to the same line as the procedure.

      d. Reduction modifier

      A modifier that reduces the value, by using a percentage value or a unit value, of a procedure code. This modifier should be added to the same line as the procedure code.
        e. Time modifier

        A modifier that serves to add additional costs to procedure codes that are billed according to time (in minutes). This must be added to the same line as the procedure.

        f. Assistant modifier

        A modifier that serves to determine the percentage and money that needs to be paid to the assistant per certain procedures from the Practice.

        How are codes and modifiers controlled and managed?

        The range of medical services that are possible in the modern world has resulted in a wide range of codes and modifiers, each with a possible range of prices and charge types. Codes are analysed and developed by the South African Medical Association (SAMA) and can be found in the SAMA book.

        The codes are developed in conjunction with a range of professional bodies and given to the Medical Schemes Council for review, publication and distribution. There are two types of codes:

        1. RPL (Reference Price List)
        2. CCSA (Complete CPT for South Africa) and is only used by surgeons. 

        Medical code categories:

        The following medical code categories are available:

        • Consultation Services
        • Clinical Procedures
        • Materials
        • Medicines
        • Modifiers
        • Other kinds of services