South African Medical Association

The following is an overview of two commonly-encountered modifiers:

General Modifiers: Modifiers 0004 and 0007

MODIFIER 0004

AM	0004	Procedures performed in own procedure rooms: (a) Procedures performed in doctors' own procedure rooms instead of in a hospital theatre or unattached theatre unit: as per fee for procedure + 100% (the value of modifier 0004 equals 100% of the value of the procedure performed). (b) A fee according to modifier 0004 may only be charged when an operation or procedure has a value greater than 30,00 units allocated to a single item. (c) Please note: Only the medical doctor owning/renting the facility and the equipment may charge modifier 0004. Only one person may claim this modifier for procedures performed in doctors' own procedure rooms. (d) Please note that modifier 0004 may not be used in conjunction with modifiers 0074 and 0075
	Extra information on Modifier 0004	Section G has been removed from the MDCM as the information contained in this list, was grossly outdated. The list was last published in the 2006 Doctors Billing Manual (DBM). Modern techniques have changed to such an extent, that procedures that would have been done in theatre, are now done in procedure rooms or in the doctor’s consulting rooms.

Example: Endoscopies were never performed in the consulting rooms in the past. When the doctor was prepared to take the risk to perform the procedure in his/her rooms, modifier 0004 could be added to item 1653 – Total colonoscopy However, currently endoscopic procedures, such as colonoscopies and upper gastro-intestinal endoscopies, are performed in the doctor’s rooms with the doctor’s own equipment; modifier 0004 will therefore not be applied to the account. Modifier 0074 – Own equipment, and modifier 0075 – Own procedure room, will compensate for the extra expense incurred.

Modifier 007

AM	0007	(a) Use of own monitoring equipment in the rooms: Remuneration for the use of any type of own monitoring equipment in the rooms for procedures performed under intravenous sedation - 15,00 clinical procedure units irrespective of the number of items of equipment provided (b) Use of own equipment in hospital theatre or unattached theatre unit: Remuneration for the use of any type of own equipment for procedures performed in a hospital theatre or unattached theatre unit when appropriate equipment is not provided by the hospital - 15,00 clinical procedure units irrespective of the number of items of equipment provided

Additional information:

Modifier 0007 is not appropriate for only operating a pulse oximeter or for reading the results
Modifier 0007 is appropriate for use of monitoring equipment in rooms when procedures are done under intravenous sedation
Modifier 0007 is applicable to doctors for the use of own instruments used in performing procedures in theatre, when these instruments are not supplied by the facility
- Modifier 0007 may not be used in conjunction with modifier 0074

BALANCED-BILLING VERSUS SPLIT-BILLING

Difference between balanced-billing and split-billing

Balanced-billing is when the service provider sends two identical accounts to both the patient and the scheme indicating the full amount for the service delivered, but specifying the portion owed by the patient and the portion of benefits the medical scheme is prepared to pay for the service rendered.

Split-billing occurs when a medical practitioner sends two separate accounts, one to the patient and one to the medical scheme that presents different amounts for the same service.

In other words the account to the patient only reflects the amount that the patient is responsible for, while the claim to the medical scheme only reflects the amount equal to the benefits the medical scheme is prepared to pay for the service rendered.

Therefore balanced billing on one account, as opposed to split billing on separate accounts, is perfectly admissible.

Balanced-billing

It is permissible to make use of columns on the account to indicate which portion of the total amount constitutes the medical schemes benefit portion (first column) and the balance portion (second column).

The final column should reflect the total charge for a particular service.

Thus one account reflects the medical scheme benefit portion, the amount payable by the patient and the total amount for the service rendered.

Split-billing

In terms of decisions and rulings adopted by the HPCSA, it is not permissible to issue two accounts for the same service, i.e.:

(1) One account for the medical scheme benefit portion; and

(2) one account for the balance of the amount of the account not covered by the scheme's benefit for the particular service(s) provided.

Therefore one account must reflect

(1) the medical scheme benefit,

(2) the patient payable portion, and

(3) the total amount for services rendered.

Split-billing is illegal in terms of the following laws:

1. According to the National Health Act (Act 61 of 2003) and section 53 (1)(b) of the Health Professions Act 56 of 1974, providers are required to disclose and obtain agreement on the cost implications of treatment from their patient and their patient’s Scheme before the consultation and/or treatment is to begin.

2. Also in terms of the Medical Schemes Act 131 of 1998, a healthcare practitioner is required to reflect the full cost and nature of the service rendered on all accounts and is not permitted to charge a patient an amount upfront without that amount being included on the statement sent to the medical scheme and/or the patient.

	Balance-billing	Split-billing
	This method of billing is legal. A doctor submits one account to the patient and the same account to the patient’s medical scheme.	This method of billing is illegal. A doctor submits two different accounts; one to the patient and another to the patient’s medical scheme.
Example 1	A doctor submits an account of R500 for his consultation fee to the patient and the patient’s Scheme. The doctor keeps both the patient and their Scheme in the loop by ensuring there is transparency in the request for payment to be made. The account may specify the amount that the Scheme must pay and the amount that the patient must pay.	A doctor’s consultation fee is R500. The doctor submits an account of R300 to be paid by the Scheme from the patient’s available benefits and then submits a separate account to the patient for the remaining R200 which is more than likely not covered by their available benefits. Both the Scheme and the patient are unaware of the split in the amounts that they are required to pay the doctor.
Example 2	A surgeon submits his claim to the patient’s medical scheme for R12 000, and the assistant also sends a percentage on the whole amount (R12 000) to medical scheme; this is considered as balance billing and is allowed.	The surgeons account amounts to R12 000. The surgeon submits an account of R6 000 to the medical scheme and sends another account to the patient for R6 000, it will be then considered as split billing which is not allowed. The assistant will send a separate account to the patient’s medical scheme for a percentage of the R12 000, this will cause discrepancies at the medical scheme and the assistant’s account will be rejected.

General Modifiers: Modifiers 0004 and 0007

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