Coding: Keeping it simple....
The SAMA Coding Department appreciates the fact that doctors are often faced with challenging or difficult scenarios when it comes to coding, not only when they are in their practices, but also when getting calls off site, such as on the golf course or relaxing at home.
In most of these instances they will not know how to bill for the specific cases in question. So, to assist our doctor members with the basic upfront knowledge of coding with which they should be armed, we will now be publishing-each month in Private Practice News - frequently asked questions, related common scenario's and interpretations submitted by our doctors and the correct codes that should be applied in the specific cases presented.
Let's begin................
In this edition we shall look at the description and the interpretation regarding Items 0145, 0146, 0126 and 0147
From 1 January 2018 a new item for Unscheduled consultations/visits AT the doctor's home or rooms are applicable and the wording of item 0146 is amended to limit the use for EMERGENCY consultations/visits AT the doctor's home or rooms
Item 0145
For consultation/visit away from the doctor's home or rooms (non-emergency): ADD only to the consultation/visit items 0190-0192, items 0173-0175, items 0161-0164, items 0166-0169, items 0151-0153, or item 0109 as appropriate. Note: Only one of items 0145, 0146, 0126 or 0147 may be charged and not combinations thereof
Interpretations of Item 0145
- Only one of items 0145, 0146, 0126 or 0147 may be added to a consultation/visit item, (as appropriate) and not combinations thereof
- To be added to items 0190-0192, 0173-0175, 0161-0164, 0166-0169 or 0151-0153 (as appropriate) for a non-emergency visit away from the consulting rooms or doctor's home
- To be added to item 0109 for subsequent hospital visits (not applicable to medical scheme benefits)
- Refer to Rule Q(a) for first hospital visit in Intensive Care/High Care unit after same-day initial visit in rooms
- The patient is responsible for the payment if his/her medical scheme does not grant benefits for this service
- Rule P is only applicable to emergency travel to a place where the doctor does not normally perform voluntary services, such as hospital visits.
Item 0146
For an EMERGENCY consultation/visit at the doctor's home or rooms: ADD only to the consultation/visit items 0190-0192, items 0161-0164 or items 0151-0153, as appropriate (refer to general rule B). Note: Only one of items 0145, 0146, 0126 or 0147 may be charged and not combinations thereof Please note that item 0146 are to be used for an Unscheduled or an Emergency consultation/visit - this will be corrected on the eDBM 2013
Interpretations of Item 0146
- Only one of items 0145, 0146, 0126 or 0147 may be added to a consultation/visit item, (as appropriate) and not combinations thereof
- Refer to item 0126 for UNSCHEDULED consultation/visit at doctor's rooms or home
- To be added to items 0190-0192 (as appropriate) for emergency consultations in rooms
- To be added to items 0190-0192 (as appropriate) for consultations by doctors normally using 24-hour emergency facilities
- The patient is responsible for the payment if his/her medical scheme does not grant benefits for this service (not applicable to Compensation Fund cases)
- Applicable to Compensation Fund cases for after-hours emergency only (refer to Rule B)
- Rule P is only applicable to emergency travel to a place where the doctor does not normally perform voluntary services, such as hospital visits
Item 0147
For an EMERGENCY consultation/visit AWAY from the doctor's home or rooms, all hours: ADD only to the consultation/visit items 0190-0192, items 0173-0175, items 0161-0164, items 0166-0169 or items 0151-0153, as appropriate. Note: Only one of items 0145, 0146 or 0147 may be charged and not combinations thereof
Interpretations of Item 0147
- Only one of items 0145, 0146 or 0147 may be added to a consultation/visit item, as appropriate, and not combinations thereof
- To be added to items 0190-0192, 0173-0175, 0161-0164, 0166-0169 or 0151-0153 (as appropriate) for an emergency visit away from the consulting rooms or doctor's home
- Not to be added to items 0190-0192 for consultations by doctors normally using 24-hour emergency facilities
- Not appropriate to add to items in the case of confinements in after-hour periods, where a global obstetric fee is charged
- The patient is responsible for the payment if his/her medical scheme does not grant benefits for this service (Not applicable to Compensation Fund cases)
- Applicable to Compensation Fund cases for after-hours emergency only (refer to Rule B)
- Item 0147 may be added to items 0151-0153 (as appropriate) when an elective work list was not submitted to the anaesthesiologist/anaesthetist by 16h00 on the day prior to the procedure(s)
- Rule P is only applicable to emergency travel to a place where the doctor does not normally perform voluntary services, such as hospital visits.
Additional Information
Up to 2000, items 0116, 0117, 0118, 0119, 0104, 0113, 0120 and 0122 referring to either 'doctor must travel', 'doctor does not travel' and 'after hours' appeared in the description of the wording in the SAMA coding structure. However, these codes were deleted and replaced with consultation codes and item 0145, 0146 and 0147. The reference then, was made to emergency or unscheduled consultations in the doctor's rooms or away from the doctor's rooms. The words 'after hours' that appeared in some of the items was replaced with 'all hours', (Refer to General Rule B- Normal hours and after hours)
Normal versus after hours: Due to the fact that medical practice has changed over the years and doctors elect to open their offices at times other than between 08:00-17:00 (weekdays) and 08:00-12:00 (Saturdays), the term 'after-hours' only applies outside the times of the doctor's normal practice hours. When the doctor advertises that he/she provide services on a Sunday, the advertised hours are considered as 'normal hours'. Any patient seen outside the doctor's office consulting hours, is seen as an unscheduled (refer to item 0126) or emergency (refer to item 0146) visit. Therefore, it is correct to use the appropriate consultation code in conjunction with item 0126 or item 0146 Item 0145 indicates that it was a non-emergency visit away from the doctor's rooms and item 0147 is for an emergency visit away from the doctor's home or rooms. Item 0146 may be used for patients without appointments, for bona fida emergency, where a patient receives precedence over booked patients. Any patient seen outside of your official consulting hours, is seen as an emergency or unscheduled patient. Therefore, it is correct to charge the appropriate consultation fee in conjunction with item 0146. If the patient has requested to see the doctor outside of office hours, the appropriate consultation code, item 0148 - Elective after-hours service on request of the patient or family (non-emergency), may be charged. When patients present themselves in your office without an appointment and insist that they see you immediately, the patient considers this as an emergency and you have to deal with it as such.Therefore, item 0146 or 0126 may be added to items 0190-0192 (as appropriate). Coded Scenarios Unscheduled or Emergency visit Patient came in with severe abdominal pain without any appointment. Patient was seen in between other appointments - non specific abdominal pain Item 0190 Consultation Item 0146 Emergenc consultation in rooms After hour visit Patient came in with a common cold after the surgery has closed and insist to see doctor for a sinusitis as it was inconvenient to come during office hours. Item 0190 Consultation Item 0146 Unscheduled consultation in rooms Item 0190 Consultation Item 0126 Unscheduled consultation in rooms Item 0148 Elective after hours services on request of the patient or family (non emergency) NB: This item is not covered by medical scheme benefits) Home Visit Frail patient with severe cough and fever. Retirement village phones and asks for a visit to examine the patient. Item 0190 Consultation Item 0145 Consultation away from the doctor's home or rooms Item 0190 Consultation Item 0147 Emergency consultation away from the doctor's home or rooms Hospital Visits A Doctor is asked to come see a patient in the hospital ward away from his own rooms Item 0145 Consultation away from the doctor's home or rooms Item 0173 Consultation Item 0147 Emergency consultation away from the doctor's home or rooms
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