*Modifier 0006 is the exception where it indicates that the aftercare is done by the referring doctor after the procedure was done by a specialist in a smaller centre - thus the specialist travelled to the smaller centre, did the procedure and the patient’s GP is looking after the patient during the post-operative care.
Rule G is in place so that the same service is not charged for twice. For example, a surgeon is remunerated for time to care for patients post-operatively and into their recovery period post discharge. In the event of such care being delegated to a colleague, this would then levy an additional charge. Essentially the patient or medical scheme will be paying twice for the same service. Rule G has been incorporated to avoid instances like these.
The South African Society of Anaesthesiologists have recommended the following:
1. In case of an uncomplicated surgical procedure and patient, the surgeon is (in terms of coding rules) remunerated for the care of the patient. Any funder (patient funders included) would be within their right to not pay additional fees to other practitioners for this expected and standard care.
2. In the case of a complicated patient or procedure that is complicated, additional ICD codes would be appropriate to the patient and must be reported by any professional delivering care additional to the surgeon’s post-operative care. The failure to report these codes give no insight into a funder as to why a patient required more than expected post-operative care. The primary surgical code should still appear on the colleague’s invoice as well as applicable additional codes. The concerns are as follows:
a. Many schemes expect coding of all parties to match and remain consistent and will not reimburse outside of this.
b. Many schemes require the hospital case manager to submit additional ICD 10 codes who are often ill equipped to apply such coding. They have no insight into the patient and their care and do not ensure the coding is correct resulting in invoices being rejected from the practitioners.
c. Certain procedures and inherently complicated with more intensive post-operative care requirements outside of the surgeon’s domain of care. /such instances may be poorly catered for with respect to specific ICD 10 coding.
3. In the case of anaesthetic consultations and anaesthetic required care such as pain management (outside the domain of the surgeon e.g. PCA, epidural care) in the post-operative patient, this is specifically excluded for in Rule G and may be reported using the same ICD 10 codes as for surgical procedure.
4. Rule G applies to patients admitted to High Care or ICU procedurally. Clearly these patients are more likely to have other co-morbidities and may require multi-disciplinary care within the prescripts of Rule G. In terms of ICU coding:
• Doctors involved need to decide who the Primary medical doctor is. This can be indicated on the ICU chart so that all other doctors involved can communicate with him/her
• A decision needs to be made on the Category of the patient and all involved medical doctors should use the appropriate codes. It would be better for the Category of the patient to also be indicated on the chart by the Primary medical doctor for all to see.
• The correct, appropriate, ICD-10 codes need to be used by all treating doctors and this may need to be changed after admission and hospital administration staff encouraged to update these codes daily.
• When billing:
+ Only one doctor can code item 1204 and the rest item 0190. Item 1204 should only be used for Category 1 patients.
+ Category 2 patients, where the Primary medical doctor uses either items 1205, 1206 or 1207 – all other medical doctors can only use item 0109.
+ One should only use code item 1210 when a patient is a category 3 or a category 2 with multi-organ failure and on subsequent days. On the first day the Primary medical doctor uses item 1208 and all supporting doctors’ use item 1209. In other words one can use item 1210 if the Primary medical doctor is also using item 1210.
*** Please note that the specialist of another discipline must obtain specific authorisation for the hospital service and cannot simply ride on the specific specialist for e.g. Orthopaedic procedural authorisation.
Many Schemes now insist on separate authorisation per clinical and medical necessity for co-attending multi-disciplinary team; physiotherapist, dietician, OT, specialised radiology all require separate PAR.
The global fee as appearing in the CPT (Current Procedural Terminology) is defined as: