Medscheme Will Process Payments According to the Information Stated Above and Will Implement
Dear Healthcare Professional,
Medscheme's interpretation of codes: 0146, 0147 and 0148
The South African Medical Association (SAMA) changed their definition of after- hours (in the SAMA billing guidelines) stating that
practices who advertise being open from 07:00 to 19:00 can no longer bill code 0148 for patients seen after 17:00 or before 08:00.
Medscheme has decided to keep the original SAMA definition of office hours, i.e. 08:00 to 17:00 from Monday to Friday and 08:00
to 13:00 on Saturday. Therefore, services rendered outside of these hours are defined as being after hours.
Since there are a number of differing views on this change on the description for this code, Medscheme (following discussion with
the IPA Forum and our administered Schemes) has decided to apply the following definitions for codes 0146, 0147 and 0148:
definition: / Code 0146: For an emergency
consultation/visit at the doctors'
home or rooms, all hours. / Code 0147: For an emergency
consultation/visit away from the
doctor's home or rooms, all
hours, when the doctor has to
travel. / Code 0148: For elective after-hour
services on request of the patient or
family (non- emergency) (refer to
general rule B)
Application
to claims as
per SAMA
descriptor: / Only add code 0146 to the
consultation/visit codes 0190-0192;
0161-0164 or 0151-0153 as
appropriate. Note: Only one of the
following codes may be charged
and not combinations thereof. / Only add to the consultation/visit
codes 0190-0192, 0173-0175, 0161-
0164, 0166-0169 or 0151-0153, as
appropriate. Note: Only one of codes
0145, 0146 or 0147 may be charged
and not combinations thereof. / Only add 50% of the fee for the
appropriate consultation/visit codes
(only to be used with codes 0190-0192,
0173-0175; 0161-0164; 0166-0169 or
0151-0153) and reflect this as a
separate code 0148.
Take note: / In the case of an emergency, you
can legitimately charge for code
0146. Since emergencies are
unscheduled consultations, code
0146 will apply any time of the day,
regardless of whether the
emergency took place during
normal working hours or not.
In the event of a perceived
emergency which turns out to be a
non-emergency in the doctor's opinion,
you may not bill code 0146.
The member may be
charged code 0148 if the
consultation was after hours (as
defined) but this will be for
their own account since 0148
codes are not funded by
Medscheme administered Schemes. / In the case of an emergency, when
the doctor has to travel way from
his/her rooms, you can legitimately
charge for code 0147. Since
emergencies are unscheduled
consultations, code 0147 will apply
any time of the day, regardless of
whether the emergency took place
during normal working hours or not.
In the event of a perceived
emergency which turns out to be a
non-emergency in the doctor's opinion,
you may not bill code 0147.
The member may be
charged code 0148 if the
consultation was after hours (as
defined) but this will be for
their own account since 0148 codes
are not funded by Medscheme
administered Schemes. / This code is used when, for example, a
patient or the family request the doctor
for a non-emergency consultation/visit
outside of the normal hour period.
Medscheme administered Schemes do
not fund code 0148. If a member is
charged code 0148 it is for their own
account. If a member wishes to consult
your practice outside your office hours
and it's not an emergency, the Scheme
will only pay the agreed tariff fee for a
normal consultation. The additional fee
that you charge for an after hour
consultation will need to be paid by the
member. This should be reflected as
a balanced bill and not a split bill.
Medscheme will process payments according to the information stated above and will implement monitoring processes to ensure
adherence.
Kind regards,
Medscheme Healthcare Professional Relations Department