Add-on codes for unscheduled and emergency visits
Anton van Schalkwyk, Medical Coding Specialist, SAMA
There exists a lot of confusion on when the use of add-on codes for consultative services are permitted with doctors’ visits. Correct coding is of utmost importance to help ensure the sustainability of private healthcare in South Africa. These add-on codes are increasingly being investigated by the medical schemes for abuse and it therefore becomes all the more important that medical doctors as well as funders ensure that they understand the rules that govern these codes.
Important Note: The most important part to remember about items 0145, 0146, 0126 and 0147 is that one may use only one at a time and not combinations thereof.
Add-on item 0145
- For consultation/visit AWAY from the medical doctor’s home or rooms (non-emergency):
- ADD only to the consultation/visit items 0190-0193, items 0173-0175, items 0161-0164, items 0166-0169, items 0151-0153 or item 0109 as appropriate.
- It is important to note that for item 0109 (subsequent hospital visits), item 0145 is excluded from Medical Scheme benefits.
Example: The doctor visits patients in a retirement home for non-emergencies. Also to be used for a non-emergency first visit in the hospital when it is a non-emergency admission.
Add-on item 0146
- For an EMERGENCY consultation/visit AT the medical doctor’s home or rooms.
- ADD to the consultation/visit items 0190-0196, items 0161-0164, or items 0151-0153.
- Refer to item 0126 for UNSCHEDULED consultation/visit at doctor’s rooms or home.
- To be added to items 0190-0193 (as appropriate) for consultations/visits in the doctor’s rooms.
- It is appropriate for doctors working at 24-hour emergency facilities to use this code when appropriate.
Important Coding Tips:
- Definition of an Emergency medical condition: The Medical Schemes Act 131 of 1998 defines it as “the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a body organ or part, or would place the person’s life in serious jeopardy.”
- In cases of bona fide emergency, ensure that the ICD-10 coding reflects the condition that would define the case as an emergency.
- The diagnosis after the visit is not enough to classify the case as an emergency visit. If the patient presents with symptoms severe enough to indicate that it might be perceived as a medical emergency it would be enough to code item 0146.
Example: The patient presents with symptoms that is perceived as a possible myocardial infarction. Immediate attention could possibly lead to immanent death. Even if the diagnosis is not myocardial infarction, at the time it was perceived and handled as an emergency and may be coded with item 0146.
Example: The patient comes into the consulting rooms without an appointment, with severe symptoms that requires immediate attention. The diagnosis is that of Hypoglycaemia. The visit is coded with add-on item 0146 to items 0190-0193 as appropriate with ICD-10 code E16.2 in order to confirm diagnoses of the emergency.
Add-on item 0126
- For an UNSCHEDULED consultation/visit AT the doctor’s home or rooms
- Not appropriate to add to items in the case of confinements in the after-hour periods, where global obstetric units are coded.
- ADD only to the consultation/visit items 0190-0193, items 0161-0164 or items 0151-0153.
- May not be added to items 1204-1210
Important note: This item may not be used by practices where patients are being seen on a first come first serve basis without scheduled appointments.
Example: The practice has to fit a patient in between scheduled appointments. The patient did not contact the practice before coming in for a consultation. It does not qualify as an emergency, but the patient cannot wait until the next day for a scheduled appointment.
Add-on item 0147
- For an emergency OR unscheduled consultation / visit AWAY from the medical doctor’s home or rooms, all hours
- ADD only to the consultation/visit items 0190-0193, items 0173-0175, items 0161-0164, items 0166-0169 or items 151-0153, as appropriate.
- Not to be added to items 0190-0193 for consultations by doctors normally using 24-hour emergency facilities
- Not to be added to items 1205-1210
- Not appropriate to add to items in the case of confinements in after-hour periods, where global obstetric units are coded.
- Item 0147 may be added to items 0151-0153 (as appropriate) when an elective work list was not submitted to the anaesthesiologist/anaesthetist by 16:00 on the day prior to the procedure(s)
Important coding note: Item 0147 should not to be used when the patient is being admitted for planned surgery and should therefore not be used as a standard add-on for all first consultations in the hospital.
Example: Doctor is being called by the emergency rooms to attend to a patient. The patient arrived with a series of stab wounds to the abdomen and needs emergency surgery.
Example: Doctor is being called out to see a patient at a retirement home to treat a case of the flu. The patient is bedridden and is difficult to move. It is not an emergency, but it is an unscheduled appointment.
It must be stressed that when the Medical Scheme rejects the occurrence of one of these add-on codes on the claim, it does become a matter between the practice and the patient.