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List of medical modifiers

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					                                      List of medical modifiers – 2002
Explanation - In the column “How to apply”:
 When the modifier should be used as a tariff code, the value of the modifier will be fixed and the modifier is processed on a
  separate line.
 When the modifier should be used as a modifier code, the value of the modifier must be added to the value of the procedure
  and processed on the same line.

              How to
Modifier      apply                                                      Explanation                                                             Value
                             Radiology – Disc 38: A benefit applicable where the radiologist is requested to give a written report on      BHF: R 98.00
0002         Informational   X-rays taken elsewhere and submitted to him. Use tariff code 0141 to assess the claim.                        SAMA: R 232.50

                             Additional fee for procedures performed in doctor’s room instead of in a hospital theatre or unattached
                             theatre unit. Enter modifier 0004 on line 6 under the heading “dt-from” to instruct the system to calculate
                             an additional R212.00.                                                                                        Procedure plus:
                             A list of tariff codes for which modifier 0004 may not be quoted have been published in the BHF               BHF: R 212.00
0004         Modifier code   Recommended Scale of Benefits [Government Gazette] (pages 164 – 172).                                         SAMA: 100%




                                                                                                                                             1      06/05/11
              How to
 Modifier      apply                                                      Explanation                                                            Value
                            For more than one therapeutic procedure/operation performed under the same anaesthetic, the fee
                            shall be:
                            100% of the BHF /SAMA tariff for the most expensive procedure
                            75% of the BHF /SAMA tariff for the second most expensive procedure - use modifier 0005 to pay 75%
                            50% of the BHF /SAMA tariff for the third most expensive procedure – use inhouse modifier 9105 to
                            pay 50%
                            25% of the BHF /SAMA tariff for the fourth and subsequent procedures – use inhouse modifier 9205 to
                            pay 25%
                            Notes: Integumentary system (skin & its appendages, i.e. hair, nails, sweat and sebaceous glands) -
                            Modifier 0005 is not applicable to those tariff codes where the explanation refers to “subsequent” or
                            “maximum for” or “each additional” as the benefit has already been reduced.
                            Modifier 0005 is not applicable to any tariff code which is preceded by a “+” as such a tariff code is
                            complementary to a preceding tariff code and is therefore not subject to reduction.
                            Modifier 0005 is also not applicable to tariff codes 0473, 0507, 0539, 0541, 0543, 0545, 0661, 0663,
                            0667, 0669, 0673, 0857, 0887, 0929, 1139, 1155, 1273, 1346, 1347, 1356, 3049 & 5770 – 100% of the
0005        Modifier code   benefit is always payable.

                                                                                                                                           Disc 32 & 33 –
                                                                                                                                           BHF: R 70.70
                            Where specialists visit smaller centres to perform procedures, but are not available for the after-care, the   SAMA: R 155.00
                            fee for these particular procedures are exclusive of after-care. An additional fee is then payable to the      Other disc –
                            referring practitioner who performs the after-care and who must quote modifier 0006. Use tariff code           BHF: R 70.00
0006        Informational   0109 to assess the claim.                                                                                      SAMA: R 155.00

                            Additional fee for the use of any type of own monitoring equipment in the doctor’s rooms for
                            procedures performed under intravenous sedation
                                                                               OR
                            Additional fee for the use of any type of own equipment for procedures performed in a hospital theatre         BHF: R 79.50
0007        Tariff code     or unattached theatre unit. Use modifier 0007 as the tariff code to assess the claim for the equipment.        SAMA: R 232.50




                                                                                                                                             2     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                            Value
                            The fee for a Specialist Assistant is 33.33% of the benefit payable to the specialist surgeon. First use
                            memory code 90009 on line 6 to link every procedure for which the assistant must be paid. Then use
                            memory code 90009 as the tariff code and modifier 0008 on line 6 under the heading “dt-from” to
0008        Modifier code   instruct the system to calculate the Specialist Assistant’s fee.

                            The fee for a General Practitioner Assistant (Disc 14 & 15) is 20% of the benefit payable to the
                            specialist surgeon. First use memory code 90009 on line 6 to link every procedure for which the GP            Minimum fee –
                            assistant must be paid. Then use memory code 90009 as the tariff code and modifier 0009 on line 6             BHF: R 190.80
0009        Modifier code   under the heading “dt-from” to instruct the system to calculate the GP assistant’s fee.                       SAMA: R 558.00

                            The fee for local anaesthetic shall be calculated according to the basic anaesthetic units for the specific
                            operation.
                             A fee may only be charged for an operation or a procedure having a value greater than 30.00 clinical
                               procedures units (i.e. 31.00 or more clinical procedure units allocated to a single item),
                             Anaesthetic time may not be charged for, but the minimum fee as per modifier 0036 shall be
                               applicable.
                             Not applicable to tariff codes 1132, 1252, 1587, 1653 & 1949.
                             Not applicable to Radiological procedures (such as angiography and myelography).
                             No fee may be levied for topical application of local anaesthetic (e.g. no gels, sprays or cream).
                             Modifier 0010 (local anaesthetic) may not be added on to the surgeon’s account for procedures that
                               were performed under general anaesthetic (modifiers 0035 & 0036).                                          Minimum fee –
                             Enter modifier 0010 on line 6 under the heading “dt-from” to instruct the system to pay the fee for         BHF: R 160.14
0010        Modifier code      local anaesthetic.                                                                                         SAMA: R 456.24

                            The benefit for any bona fide justifiable emergency procedure (all hours) undertaken in an operating
                            theatre will be calculated per 30 minutes or part of 30 minutes of the operating time and payable to all      Per 30 min or
                            members of the surgical team. Use modifier 0011 as the tariff code and enter the number of minutes            part of 30 min
                            plus the letter “m” on line 6 under the heading “Dp” to instruct the system to calculate the emergency        BHF: R 63.60
0011        Tariff code     fee.                                                                                                          SAMA: R 186.00




                                                                                                                                            3     06/05/11
              How to
 Modifier      apply                                                      Explanation                                                           Value
                            The benefit for a related endoscopic examination done at an operation, shall be 50% of the BHF /SAMA
                            tariff. Modifier 0013 is not applicable to tariff code 0667. Enter modifier 0013 on line 6 under the
0013        Modifier code   heading “dt-from” to instruct the system to calculate 50%.

                            When an operation is performed that has been performed previously by another surgeon, e.g. a revision
            Informational   or repeat operation, the benefit shall be the full benefit plus an additional fee to be negotiated under
            (Read           General Rule J. Once the fee has been negotiated, use Inhouse code 99230 to assess the additional
0014        explanation)    amount charged.

                            Where intravenous infusions (including blood and blood cellular products) are administered as part of the
                            after-treatment after the operation or confinement, no extra fee shall be charged as this is included in the
0015        Informational   global operative or maternity fee

                            When desensitization, intravenous, intramuscular or subcutaneous injections are administered by the
                            practitioner himself to patients who attend the consulting rooms, a first injection forms a part of the
                            consultation. All subsequent injections for the same condition should be charged at 50% of the
                            appropriate consultation fee for a general practitioner. Use modifier 0017 as the tariff code to pay the       BHF: R 46.05
0017        Tariff code     50%.                                                                                                           SAMA: R116.25

                            The benefit for persons with a BMI of more than 35 (calculated according to kg/m2) will be the fee for
                            the procedure plus 50% for surgeons and a 50% increase in anaesthetic time units for anaesthetists.
                            Enter modifier 0018 on line 6 under the heading “dt-from” to instruct the system to calculate the
0018        Modifier code   additional 50%.

                            The benefit for surgery on neonates (up to and including 28 days after birth) and low birth weight infants
                            (less than 2500g) under general anaesthesia, excluding circumcision, shall be the fee for the procedure
                            plus 50% for surgeons and a 50% increase in anaesthetic time units for anaesthetists. Enter modifier
0019        Modifier code   0019 on line 6 under the heading “dt-from” to instruct the system to calculate the additional 50%.




                                                                                                                                            4     06/05/11
              How to
 Modifier      apply                                                      Explanation                                                           Value
                            When conscious sedation is conducted outside of a theatre/hospital suite, modifier 0020 should be
0020        Informational   quoted to indicate that there will be no hospital/theatre account.

0021        Informational   Anaesthetic fees are determined by obtaining the sum of the basic anaesthetic units and the time units.

                                                                                                                                          First 60 min – per
                                                                                                                                          15 min
                                                                                                                                          BHF: R 53.38
                            The benefit for anaesthetic time shall be per 15 minutes or part thereof, calculated from the                 SAMA: R 152.08
                            commencement of the anaesthetic, i.e. 2.00 anaesthetic units per 15 minutes or part thereof, provided         After 60 min –
                            that should the duration of the anaesthetic be longer than 1 hour, the number of units shall, after I hour,   per 15 min
                            be 3.00 anaesthetic units per 15 minutes or part thereof.                                                     BHF: R 80.07
0023        Informational   Add the fees charged for modifier 0023 to the fees charged for the procedure.                                 SAMA: R 228.12

                            If a pre-operative assessment of a patient by the anaesthetist is not followed by an operation, it will be
0024        Informational   regarded as a consultation at a hospital or nursing home.

                            The benefit for the period of time when the personal professional attention of the anaesthetist is
                            necessary for the well-being of the patient after the operation, until the patient may, with reasonable
                            safety, be placed under the customary post-operative supervision.
0025        Informational   Add the fees charged for modifier 0025 and modifier 0023 to the fees charged for the procedure.

                            Where more than one operation is performed under the same anaesthetic, the benefit for the
                            anaesthetist will be calculated according to the basic anaesthetic units of the operation with the highest
0027        Informational   number of units. To calculate the anaesthetist’s benefit, disregard the other operations.

                            According to BHF this modifier is currently under review. Reject with Error code 2830: “Not chargeable:
0028        Tariff code     Stats purposes only – SASA”




                                                                                                                                            5      06/05/11
              How to
 Modifier      apply                                                       Explanation                                                            Value
                            The benefit for an assistant anaesthetist will be calculated on the same basis as in the case of a
                            general practitioner anaesthetist – two-thirds of the benefit for the specialist anaesthetist, with a           Minimum fee –
                            minimum benefit applicable (Modifier 0036). Enter modifier 0029 on line 6 under the heading “dt-from”           BHF: R 160.14
0029        Modifier code   to instruct the system to calculate the assistant anaesthetist’s fee.                                           SAMA: R 456.24

                            According to BHF this modifier is currently under review. Reject with Error code 2830: “Not chargeable:
0030        Tariff code     Stats purposes only – SASA”

                            Treatment with intravenous drips and transfusions is considered part of the normal treatment in
                            administering an anaesthetic and no additional fees may be charged for such services, when rendered
                            either prior to or during actual theatre or operating time.
0031        Informational   Tariff codes 0205, 0206 & 0207 may not be charged at the same time as the anaesthetic.

                            The benefit for anaesthesia administered to patients in the prone position (lying face down on the
                            operating table) shall have a minimum of 4.00 basic anaesthetic units. When the basic anaesthetic units
                            for the procedure are 3.00, one extra anaesthetic unit should be added – apply modifier 0032. To apply          Amount added to
                            the modifier, enter modifier 0032 on line 6 under the heading “dt-from” to instruct the system to calculate     the Basic Unit
                            the additional unit.                                                                                            Value:
                            If the basic anaesthetic units for the procedure are 4.00 or more, no extra units should be added – reject      BHF: R 26.69
0032        Modifier code   modifier 0032. To reject the modifier, use error message 874: “Mod 0032 not applicable to this item”.           SAMA: R 76.04

                                                                                                                                            Minimum fee –
                            An anaesthetist is entitled to the full benefits subject to modifier 0035, when he is required to participate   BHF: R 186.83
0033        Informational   in the general care of a patient during a surgical procedure, but does not administer the anaesthetic.          SAMA: R 532.28




                                                                                                                                              6     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                            Value
                            The benefit for all anaesthetics administered for diagnostic, surgical or X-ray procedures on the head
                            and neck, shall have a minimum of 4.00 basic anaesthetic units. When the basic anaesthetic units for
                            the procedure are 3.00, one extra anaesthetic unit should be added - apply modifier 0034. To apply the        Amount added to
                            modifier, enter modifier 0034 on line 6 under the heading “dt-from” to instruct the system to calculate the   the Basic Unit
                            additional unit.                                                                                              Value:
                            If the basic anaesthetic units for the procedure are 4.00 or more, no extra units should be added – reject    BHF: R 26.69
0034        Modifier code   modifier 0034. To reject the modifier, use error message 811: “Not chargeable with this procedure”.           SAMA: R 76.04

                                                                                                                                          Minimum fee –
                            The minimum benefit for a specialist anaesthetist (Disc 10) shall be 7.00 anaesthetic units. The              BHF: R 186.83
0035        Informational   system is programmed not to pay the specialist anaesthetist less than the minimum fee.                        SAMA: R 532.28

                            The benefit for a GP anaesthetist (Disc 14 & 15) shall be two-thirds of the benefit for a specialist
                            anaesthetist (basic + time + applicable modifier) with a minimum of 6.00 anaesthetic units. The system
                            is programmed not to pay the GP anaesthetist less than the minimum fee.                                       Minimum fee –
                            Note: Do not use modifier 0036 when assessing tariff code 1461 (anaesthesia for all Dental procedures),       BHF: R 160.14
0036        Modifier code   as the system has been programmed to calculate the correct 2/3 (two-thirds) fee without modifier 0036.        SAMA: R 456.24

                            An additional benefit payable to the anaesthetist for the utilisation of total body hypothermia (the
                            deliberate and controlled reduction of body temperature as preparation for certain surgical procedures).
                            Enter modifier 0037 on line 6 under the heading “dt-from” to instruct the system to calculate the             BHF: R 80.07
0037        Modifier code   additional fee.                                                                                               SAMA: R 228.12

                            An additional benefit payable to the anaesthetist for peri-operative blood salvage (the blood lost during
                            the procedure is suctioned up, filtered and fed back into the patient’s body). Enter modifier 0038 on line    BHF: R 106.76
0038        Modifier code   6 under the heading “dt-from” to instruct the system to calculate the additional fee.                         SAMA: R 304.16




                                                                                                                                            7     06/05/11
              How to
 Modifier      apply                                                      Explanation                                                           Value
                                                                                                                                          First hour –
                                                                                                                                          BHF: R 80.07
                            An additional benefit payable to the anaesthetist for the deliberate control of the blood pressure. The       SAMA: R 228.12
                            benefit shall be 3.00 anaesthetic units for all cases up to the first hour and thereafter 1.00 anaesthetic    Thereafter – per
                            unit per 15 minutes or part thereof. Enter tariff code 0039 on line 4 under the heading “tariff” and enter    15 minutes
                            the number of minutes plus the letter “m” on line 6 under the heading “dp” to instruct the system to          BHF: R 26.69
0039        Tariff code     calculate the additional fee.                                                                                 SAMA: R 76.04

                            The basic anaesthetic units for procedures performed for phaeochromocytoma shall be 15.00                     BHF: R 400.35
0040        Informational   anaesthetic units. Time must then still be added to the basic anaesthetic units.                              SAMA: R 1140.60

                            An additional fee for the utilisation of hyperbaric pressurisation. Motivation is required. Enter modifier    BHF: R 80.07
0041        Modifier code   0041 on line 6 under the heading “dt-from” to instruct the system to calculate the additional fee.            SAMA: R 228.12

                            An additional benefit payable to the anaesthetist for the utilisation of extracorporeal circulation (e.g.
                            during open-heart surgery the blood flow to the heart is stopped and relayed to an iron heart and from
                            there back into the patient’s body while the surgeon(s) operate on the patient’s own heart). Enter            BHF: R 80.07
0042        Modifier code   modifier 0042 on line 6 under the heading “dt-from” to instruct the system to calculate the additional fee.   SAMA: R 228.12

                            An additional benefit payable to the anaesthetist for administering an anaesthetic to a patient under one
                            year of age. Enter modifier 0043 on line 6 under the heading “dt-from” to instruct the system to calculate    BHF: R 80.07
0043        Modifier code   the additional fee.                                                                                           SAMA: R 228.12

                            An additional benefit payable to the anaesthetist for administering an anaesthetic to neonates (i.e. up to
                            and including 28 days after birth). Modifier 0044 may be charged in addition to modifier 0043. Enter          BHF: R 80.07
0044        Modifier code   modifier 0044 on line 6 under the heading “dt-from” to instruct the system to calculate the additional fee.   SAMA: R 228.12




                                                                                                                                            8      06/05/11
              How to
 Modifier      apply                                                       Explanation                                                             Value
                            The benefit for post-operative alleviation of pain
                             when a regional or nerve block procedure is performed, can be claimed for by quoting tariff code
                                 0109, provided that it is not the primary anaesthetic technique
                             when a second medical practitioner has administered the regional or nerve block for post-operative
                                 alleviation of pain can be claimed for according to the particular procedure for instituting the therapy.
                                 Revisits should be charged for according to tariff code 0109.
                            NOTE: None of the above is applicable to routine post-operative pain management, i.e. intramuscular,             BHF: R 70.00
0045        Informational   intravenous or subcutaneous administration of opiates or NSAID (nonsteroidal anti-inflammatory drug).            SAMA: R 155.00

                            Where in the treatment of a specific fracture or dislocation, an initial procedure is followed within one
                            month by an open reduction, internal fixation, external skeletal fixation or bone grafting on the same
                            bone, the fee for the initial treatment of that fracture or dislocation shall be reduced by 50%.
                            NOTE: This reduction does not include the assistant’s fee or after-hours levy. Enter modifier 0046 on
                            line 6 under the heading “dt-from” to instruct the system to calculate 50%. After one month, the full fee
0046        Modifier code   for the initial treatment is applicable. Modifier 0046 is not applicable to tariff codes 0987 to 1017.

0047        Informational   A fracture not requiring reduction shall be charged on a fee per service basis.

                            An additional benefit payable to the practitioner where in the treatment of a fracture or dislocation, an
                            initial closed reduction is followed within one month by further closed reductions under general
                            anaesthesia, shall be 27.00 clinical units for such subsequent reductions. Modifier 0048 is not
                            applicable to tariff codes 0987 to 1017. Use modifier 0048 as the tariff code to calculate the additional        BHF: R 143.10
0048        Tariff code     fee.                                                                                                             SAMA: R 418.50

                                                                                                                                             Specialist –
                            Except where otherwise specified, the benefit of 77.00 clinical units to a specialist and the benefit of         BHF: R 408.10
                            51.00 clinical units to a general practitioner in cases of compound fractures, must be added to the units        SAMA: R 1193.50
                            for the fractures, including debridement. Enter modifier 0049 on line 6 under the heading “dt-from” to           General Pract -
                            instruct the system to calculate the additional fee. Modifier 0049 is not applicable to tariff codes 0987 to     BHF: R 270.30
0049        Modifier code   1017.                                                                                                            SAMA: R 790.50




                                                                                                                                               9     06/05/11
              How to
 Modifier      apply                                                      Explanation                                                             Value
                            In cases of a compound fracture where a debridement is followed by internal fixation, modifiers 0049 &
                            0051 must be applied by paying 100% of the BHF /SAMA/SH tariff for one of these modifiers and 50% of
                            the BHF /SAMA/SH tariff for the other modifier. Modifier 0050 is not applicable to tariff codes 0987 to
0050        Informational   1017.


                                                                                                                                            Specialist –
                            An additional benefit of 77.00 clinical units to a specialist and of 51.00 clinical units to a general          BHF: R 408.10
                            practitioner is payable where fractures require open reduction, internal fixation, external skeletal fixation   SAMA: R 1193.50
                            and/or bone grafting. Enter modifier 0051 on line 6 under the heading “dt-from” to instruct the system to       General Pract -
                            calculate the additional fee. Modifier 0051 is not applicable to tariff codes 0392, 0578 and 0987 to            BHF: R 270.30
0051        Modifier code   1017.                                                                                                           SAMA: R 790.50

                                                                                                                                            Specialist –
                            An additional benefit of 32.00 clinical units to a specialist and of 21.00 clinical units to a general          BHF: R 169.60
                            practitioner is payable where fractures require percutaneous internal fixation [insertion and removal of        SAMA: R 496.00
                            fixatives (wires) in respect of fingers and toes included]. Enter modifier 0053 on line 6 under the             General Pract -
                            heading “dt-from” to instruct the system to calculate the additional fee. Modifier 0053 is not applicable       BHF: R 111.30
0053        Modifier code   to tariff codes 0987 to 1017.                                                                                   SAMA: R 325.50

                                                                                                                                            Specialist –
                                                                                                                                            BHF: R 408.10
                            An additional benefit of 77.00 clinical units to a specialist and of 51.00 clinical units to a general          SAMA: R 1193.50
                            practitioner is payable where a dislocation requires open reduction. Enter modifier 0055 on line 6 under        General Pract -
                            the heading “dt-from” to instruct the system to calculate the additional fee. Modifier 0055 is not              BHF: R 270.30
0055        Modifier code   applicable to tariff codes 0987 to 1017.                                                                        SAMA: R 790.50




                                                                                                                                             10     06/05/11
              How to
 Modifier      apply                                                      Explanation                                                            Value
                            In multiple procedures on feet, the benefit for the first foot is calculated according to modifier 0005 (0005
                            = 75%, 9105 = 50%, 9205 = 25%). The benefit for the second foot is calculated in the same way, but
                            that benefit for each procedure must be reduced to 75% - enter modifier 0057 on line 6 after the
                            applicable modifier (0005, 9105 and 9205) to instruct the system to reduce each applicable benefit to
0057        Modifier code   75%. Modifier 0057 is not applicable to tariff codes 0987 to 1017.

                            The benefit for a revision operation for a total joint replacement and immediate resubstitution (infected or
                            non-infected) shall be the benefit for the joint replacement, plus 100%. Enter modifier 0058 on line 6
                            under the heading “dt-from” to instruct the system to calculate the additional 100%. Modifier 0058 is not
0058        Modifier code   applicable to tariff codes 0987 to 1017.

                            In cases of combined procedures on the spine, both the orthopaedic surgeon and the neurosurgeon are
0061        Informational   entitled to the full fee for the relevant part of the operation performed.

                            Where two specialist work together on a replantation procedure, each shall be entitled to two-thirds of
                            the fee for the procedure. Enter modifier 0063 on line 6 under the heading “dt-from” to instruct the
0063        Modifier code   system to calculate the two-thirds. Modifier 0063 is applicable to tariff codes 0912 to 0915.

                            Where the replantation is unsuccessful, no further surgical fee is payable for amputation of the non-
0064        Informational   viable parts.

                            The benefit for additional operative procedures by the same surgeon within a period of 12 months, shall
                            be 75% of the BHF /SAMA tariff for the lesser procedure, except where otherwise specified elsewhere.
0065        Modifier code   Enter modifier 0065 on line 6 under the heading “dt-from” to instruct the system to calculate the 75%.

                            Microsurgery of the fallopian-tubes and ovaries does not qualify for benefits, but can be paid from the
                            member’s savings. Use Service code SA to pay the fee charged from the member’s savings. Modifier
0066        Informational   0066 is applicable to tariff codes 2481 to 2492.




                                                                                                                                            11     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                           Value
                            An additional benefit of 25% may be added to the BHF/SAMA tariff where microsurgery of the larynx is
                            performed. Enter modifier 0067 on line 6 under the heading “dt-from” to instruct the system to calculate
0067        Modifier code   the additional fee. Modifier 0067 is applicable to tariff codes 1117 to 1131.

                            An additional benefit of 10% may be added to the BHF /SAMA tariff when endoscopic instruments are
                            used during intranasal surgery. Enter modifier 0069 on line 6 under the heading “dt-from” to instruct the
                            system to calculate the additional fee. Modifier 0069 is applicable to tariff codes 1025, 1027, 1030,
0069        Modifier code   1033, 1035, 1036, 1039*, 1047*, 1054* & 1083*. (* = applicable as from 01 Jan 2001)

                            An additional 45.00 clinical units are payable for procedures performed through a thorascope. Enter           BHF: R 238.50
0070        Modifier code   modifier 0070 on line 6 under the heading “dt-from” to instruct the system to calculate the additional fee.   SAMA: R 697.50

                            The number of peripheral vascular tests in a single case is restricted to two per diagnosis. Tests are not
0072        Informational   justified in cases of uncomplicated varicose veins. Applicable to tariff codes 5369 to 5381.

                            When tariff code 1288 (Paediatric cardiac catheterisation) or tariff code 1289 (Paediatric cardiac
                            catheterisation) was performed on infants below the age of one year by a Paediatric Cardiologists (Disc
                            33) the benefit will be the full benefit for the procedure PLUS 100%. Use a multiplier of 2 to pay the
0073        Informational   additional 100%.

                            A benefit of only two-thirds of the BHF/SAMA tariff shall be payable where fibre optic procedures are
                            performed by means of hospital equipment. Enter modifier 0074 on line 6 under the heading “dt-from”
                            to instruct the system to calculate the two-thirds. Modifier 0074 is applicable to tariff codes 1461 to
0074        Modifier code   1817.

                            An additional 21.00 clinical units are payable where fibre optic procedures are performed in rooms with
                            own equipment. Enter modifier 0075 on line 6 under the heading “dt-from” to instruct the system to
                            calculate the additional fee. Modifier 0075 is not applicable to any of the items for diagnostic procedures   BHF: R 111.30
0075        Modifier code   in the otorhinolaryngology (ear, nose & throat) sections of the Gazette.                                      SAMA: R 325.50




                                                                                                                                          12      06/05/11
              How to
 Modifier      apply                                                      Explanation                                                          Value
                            Physical treatment - when two separate areas are treated simultaneously for totally different conditions,
                            such treatment shall be regarded as two treatments for which separate fees may be charged. Modifier
0077        Informational   0077 is applicable to tariff codes 3279 to 3304.

                            An additional 50% for the appropriate procedure is payable when testis biopsy is done combined with
                            vasogram or seminal vesiculogram or epididymogram. Enter modifier 0078 on line 6 under the heading
0078        Modifier code   “dt-from” to instruct the system to calculate the additional fee.

                                                                                                                                         Specialist –
                                                                                                                                         BHF: R 168.00
                                                                                                                                         SAMA: R 372.00
                            When a first consultation proceeds into, or is immediately followed by a medical psychotherapeutic           General Pract –
                            procedure, fees for the procedure are calculated according to tariff code 2957 for a 20-minute session       BHF: R 84.80
0079        Informational   or part thereof, provided that such a part comprises 50% or more of the time of the session.                 SAMA: R 248.00

                            Diagnostic radiology – When multiple examinations are performed, 100% of the BHF/SAMA tariff is
0080        Informational   payable for each examination.

                            Diagnostic radiology – When repeat examinations are performed, 100% of the BHF/SAMA tariff is
0081        Informational   payable for each examination.

                            When a “+” appears before a tariff code, it means that the tariff code is complementary to another tariff
0082        Informational   code on the account and the benefit should therefore not be reduced.

                            A benefit of only two-thirds of the BHF/SAMA tariff shall be payable where radiological examinations
                            are performed by means of hospital equipment. Enter modifier 0083 on line 6 under the heading “dt-
                            from” to instruct the system to calculate the two-thirds. NOTE: Modifier 0083 is not applicable to section
0083        Modifier code   19.8 (Vascular studies) and section 19.14 (Interventional Radiological Procedures) of the Gazette.




                                                                                                                                          13     06/05/11
              How to
 Modifier      apply                                                       Explanation                                                         Value
                            An additional benefit payable to the practitioner for the cost of the film that is used to take the X-ray.
                            Enter modifier 0084 on line 6 under the heading “dt-from” to instruct the system to calculate the
0084        Modifier code   additional fee for the cost of the film.

                            Vascular groups – “Film series” (tariff codes 3536 to 3574) and “Introduction to Contrast media” (tariff
                            codes 3563 & 3575) are complementary and together constitute a single examination: neither is
0086        Informational   therefore subject to increase in terms of Modifier 0080.

                            The radiologist’s benefit for participation in a team shall be 30.00 radiology units per 30 minutes or part
                            of 30 minutes for all interventional radiological procedures, excluding any pre- or post-operative
                            angiography, catheterisation, CT-scanning, ultrasound-scanning or X-ray procedures. Use modifier 0090         Per 30 min or
                            as the tariff code and enter the number of minutes plus the letter “m” on line 6 under the heading            part thereof –
                            “Dp” to instruct the system to calculate the correct benefit. Modifier 0090 is applicable to tariff codes     BHF: R 216.00
0090        Tariff code     5020 to 5056.                                                                                                 SAMA: R 513.00

                            Modifier 0091 is used to identify that the diagnostic services (e.g. MRI, X-rays, pathology tests) were
0091        Informational   rendered to hospital inpatients - patients officially admitted to hospital or day clinic.

                            Modifier 0092 is used to identify that the diagnostic services (e.g. MRI, X-rays, pathology tests) were
0092        Informational   rendered to hospital outpatients - patients not officially admitted to hospital or day clinic.

                            Radiation oncology – Only pay 100% of the BHF/SAMA tariff if the practitioner quotes modifier 0093 to
                            indicate that he used his own apparatus to perform the procedures. Reject the claim for the applicable
0093        Modifier code   modifier if no modifier is quoted. Modifier 0093 is applicable to section 20 of the Gazette.

                            Radio-isotope therapy - Appointments not kept do not qualify for benefits, but can be paid from the
0096        Informational   member’s savings. Use Service code SA to pay the fee charged from the member’s savings.

                            Pathology & Anatomical pathology – The benefit for other specialists and general practitioners shall be
0097        Informational   two-thirds of the benefit for pathologists.




                                                                                                                                          14      06/05/11
              How to
 Modifier      apply                                                     Explanation                                                         Value
                            An additional benefit of 75.00 clinical units is payable where the anaesthetist would be responsible for    BHF: R 397.50
0100        Tariff code     operating an intra-aortic balloon pump. Use code 100 as the tariff code to pay the additional fee.          SAMA: R 1162.50

                            Ultrasonic investigations – An additional 30% of the BHF /SAMA tariff is payable where aspiration of a
                            biopsy procedure is performed under direct ultrasonic control by an ultrasonic aspiration biopsy
                            transducer. Enter modifier 0160 on line 6 under the heading “dt-from” to instruct the system to calculate
0160        Modifier code   the additional 30%.

                            Ultrasonic investigations – An additional 6.00 ultrasound units are applicable where contrast is used
                            during ultrasound study. Enter modifier 0165 on line 6 under the heading “dt-from” to instruct the
0165        Modifier code   system to calculate the additional fee.




                                                                                                                                        15      06/05/11
              How to
 Modifier      apply                                                        Explanation                                                             Value
                            Applicable to Radiation oncology sections 20.1 & 20.4. Multiple areas to a maximum of 3 areas treated
                            in the same treatment session: The following values shall prevail (unless otherwise identified in the tariff)
                            where treating multiple treatment volumes/areas which add significant time and/or complexity and when
                            each treatment volume/area is clearly identified and defined:
                             100% (full value) for the first volume/area
                             67% (enter modifier 0170 on line 6 under the heading “dt-from” to instruct the system to calculate
                                 only 67% of the relevant fee) for the second volume/area and
                             33% (enter modifier 9170 on line 6 under the heading “dt-from” to instruct the system to calculate
0170        Modifier code        only 33% of the relevant fee) for the third volumes/areas.

                            Specialised radiation technique: By arrangement with the Scheme/Patient
                            The following cases are regarded as being unusually complex in nature and therefor the recommended
                            charge is the fee for the applicable code in use plus 100%. Applicable to the following tariff codes in
                            section 20.6 only: 5123 – 5125, 5902 – 5904, 5132 – 5134 & 5907 – 5909. The specialised teletherapy
                            procedures include Mantle field radiation, Inverted Y radiation, Total Nodal Irradiation (TNI), Craniospinal
                            radiation, whole body or fractionated hemi body radiation, IMRT, MLC radiation and special bema
                            considerations (multiple electron areas/volumes, proton and neutron therapy). Use a multiplier of 2 to
0172        Informational   pay the additional 100%.

                                                                                                                                              Specialist –
                                                                                                                                              BHF: R 339.20
                                                                                                                                              SAMA: R 992.00
                            The benefit for the late removal of infected total joint replacement prosthesis (including six weeks after-       General Pract -
                            care) shall be the fee for the total joint replacement of the specific joint, plus 64 units for a Specialist or   BHF: R 222.60
0886        Modifier code   42 units for a General Practitioner.                                                                              SAMA: R 651.00




                                                                                                                                               16     06/05/11
              How to
 Modifier      apply                                                      Explanation                                                       Value
                            The benefit for Tomography (conventional except where otherwise specified) shall be an additional
                            100% of the BHF /SAMA fee for the applicable tariff code, provided that if it is more than one dimension
                            the fee shall be charged for the additional investigation at 50% of the tariff with a maximum of two
                            additional investigations.
                            Enter modifier 3577 on line 6 under the heading “dt-from” to instruct the system to calculate the 100%.
3577        Modifier code   Enter modifier 3578 on line 6 under the heading “dt-from” to instruct the system to calculate the 50%.

                            The benefit for Tomography (multi-dimensional in motion) shall be an additional 150% of the BHF
3579        Modifier code   /SAMA fee for the applicable tariff code.

                            The benefit for Cinematography for the first series shall be an additional 100% of the BHF /SAMA fee
3581        Modifier code   for the applicable tariff code.

                            The benefit for Cinematography for each series after the first series shall be an additional 80% of the
3583        Modifier code   BHF /SAMA fee for the applicable tariff code.

                            Ultrasonic investigations – An additional 30% of the BHF/SAMA tariff is payable where ultrasound in
                            pregnancy is performed for multiple gestations, after fourteen weeks. Enter modifier 5104 on line 6
                            under the heading “dt-from” to instruct the system to calculate the additional 30%. Applicable to tariff
5104        Modifier code   codes 3615, 3617 & 3618.




                                                                                                                                       17     06/05/11
              How to
 Modifier      apply                                                       Explanation                                                             Value
                            For certain orthopaedic operations an additional one anaesthetic unit is payable to the anaesthetist,
                            except where the procedure refers to the bones named in modifiers 5442 to 5448. Enter modifier 5441
                            on line 6 under the heading “dt-from” to instruct the system to calculate the additional fee. This modifier
                            is only applicable to those tariff codes where the letter “M” is displayed in the column that identifies units    BHF: R 26.69
5441        Modifier code   for anaesthetists, in the BHF Scale of Benefits.                                                                  SAMA: R 76.04

                            An additional two anaesthetic units are payable for procedures involving the shoulder, scapula, clavicle,
                            humerus, elbow joint, upper 1/3 tibia, knee joint, patella mandible & temporo-mandibular joint. Enter
                            modifier 5442 on line 6 under the heading “dt-from” to instruct the system to calculate the additional fee.
                            This modifier is only applicable to those tariff codes where the letter “M” is displayed in the column that       BHF: R 53.38
5442        Modifier code   identifies units for anaesthetists, in the BHF Scale of Benefits.                                                 SAMA: R 152.08

                            An additional three anaesthetic units are payable for procedures involving the maxillary& orbital bones.
                            Enter modifier 5443 on line 6 under the heading “dt-from” to instruct the system to calculate the
                            additional fee. This modifier is only applicable to those tariff codes where the letter “M” is displayed in the   BHF: R 80.07
5443        Modifier code   column that identifies units for anaesthetists, in the BHF Scale of Benefits.                                     SAMA: R 228.12

                            An additional four anaesthetic units are payable for procedures involving the shaft of femur. Enter
                            modifier 5444 on line 6 under the heading “dt-from” to instruct the system to calculate the additional fee.
                            This modifier is only applicable to those tariff codes where the letter “M” is displayed in the column that       BHF: R 106.76
5444        Modifier code   identifies units for anaesthetists, in the BHF Scale of Benefits.                                                 SAMA: R 304.16

                            An additional five anaesthetic units are payable for procedures involving the spine (except coccyx),
                            pelvis, hip, neck of femur. Enter modifier 5445 on line 6 under the heading “dt-from” to instruct the
                            system to calculate the additional fee. This modifier is only applicable to those tariff codes where the          BHF: R 133.45
5445        Modifier code   letter “M” is displayed in the column that identifies units for anaesthetists, in the BHF Scale of Benefits.      SAMA: R 380.20

                            An additional eight anaesthetic units are payable for procedures involving sternum and/or ribs and
                            musculo-skeletal procedures which involve an intra-thoracic approach. Enter modifier 5448 on line 6
                            under the heading “dt-from” to instruct the system to calculate the additional fee. This modifier is only
                            applicable to those tariff codes where the letter “M” is displayed in the column that identifies units for        BHF: R 213.52
5448        Modifier code   anaesthetists, in the BHF Scale of Benefits.                                                                      SAMA: R 608.32




                                                                                                                                              18      06/05/11
              How to
 Modifier      apply                                                     Explanation                                                          Value
                            The benefit for an examination of a specific single anatomical region, performed with the applicable radio
                            frequency coil including T1 and T2 weighted images on at least two planes, shall be 100% of the BHF
6100        Informational   /SAMA tariff.

                            The benefit where a limited series of a specific anatomical region is performed (except bone tumour),
                            e.g. a T2 weighted image of a bone for an occult stress fracture, shall be two-thirds of the BHF /SAMA
                            tariff. Enter modifier 6101 on line 6 under the heading “dt-from” to instruct the system to calculate the
6101        Modifier code   two-thirds.

                            The benefit for all post-contrast studies (except bone tumour) shall be 50% of the BHF /SAMA tariff.
6102        Modifier code   Enter modifier 6102 on line 6 under the heading “dt-from” to instruct the system to calculate the 50%.

6103        Informational   The benefit for bone tumour post-contrast studies shall be 100% of the BHF /SAMA tariff.

                            The benefit for a limited examination of the hypophysis e.g. where a coronal T1 and sagital T1 series are
                            performed, shall be two-thirds of the BHF /SAMA tariff. Enter modifier 6104 on line 6 under the
6104        Modifier code   heading “dt-from” to instruct the system to calculate the two-thirds.

                            The benefit, where in a limited hypophysis examination, Gadolinium is administered and coronal T1 and
                            sagittal T1 series are repeated, shall be 100% of the BHF /SAMA tariff for the entire examination + the
6105        Informational   cost of the Gadolinium + the disposable items.

                            The benefit, where a MR angiography of large vessels is performed as primary examination by use of a
                            recognised angiographic software package with reconstruction capability, shall be 100% of the BHF
6106        Informational   /SAMA tariff.

                            The benefit, where a MR angiography of the vessels is performed additional to an examination of a
                            particular region by use of a recognised angiographic software package with reconstruction capability,
                            shall be 50% of the BHF /SAMA tariff. Enter modifier 6107 on line 6 under the heading “dt-from” to
6107        Modifier code   instruct the system to calculate the 50%.




                                                                                                                                         19     06/05/11
              How to
 Modifier      apply                                                       Explanation                                                        Value
                            The benefit, where only a gradient echo series is performed with a machine without a recognised
                            angiographic software package with reconstruction ability, specifying that it is a “flow sensitive series”
                            shall be 20% of the BHF /SAMA tariff. Enter modifier 6108 on line 6 under the heading “dt-from” to
6108        Modifier code   instruct the system to calculate the 20%.

                            The benefit for very limited studies to be charged at 33.33% of the BHF/SAMA tariff, e.g. MR urography
                            for renal colic, diffusion studies of the brain additional to routine brain. Enter modifier 6109 on line 6
6109        Modifier code   under the heading “dt-from” to instruct the system to calculate the 33.33%.

                            The benefit for a MRI spectroscopy shall be 50% of the BHF/SAMA tariff. Enter modifier 6110 on line 6
6110        Modifier code   under the heading “dt-from” to instruct the system to calculate the 50%.

                            The benefit, where a procedure lasts for less than 30 minutes shall be 50% of the machine fees for tariff
                            codes 3536 – 3550. The time must be specified on the account. Enter modifier 6300 on line 6 under
6300        Modifier code   the heading “dt-from” to instruct the system to calculate the 50%.

                            Where a procedure is performed by a Radiologist (Disc 38) in a facility not owned by him, the benefit
                            shall be reduced by 40% (only 60% of the benefit will be payable). Enter modifier 6301 on line 6 under
6301        Modifier code   the heading “dt-from” to instruct the system to calculate the 60%.




                                                                                                                                         20     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                          Value
                            Where a procedure is performed by a Non-Radiologist the benefit shall be reduced by 40% (only 60% of
                            the benefit will be payable). Enter modifier 6302 on line 6 under the heading “dt-from” to instruct the
6302        Modifier code   system to calculate the 60%.

                            Where a procedure is performed entirely by a Non-Radiologist in a facility owned by a Radiologist, the
                            benefit for the Radiologist owning the facility shall be 55% of the procedure units used. Modifier 6302
                            applies to the Non-Radiologist performing the procedure. Enter modifier 6303 on line 6 under the
6303        Modifier code   heading “dt-from” to instruct the system to calculate the 55%.

                            When multiple catheterisation procedures are used (tariff codes 3557, 3559, 3560 & 3562) and an
                            angiogram investigation is performed at each level, the unit value of each such multiple procedure will be
                            reduced by 20.00 radiological units for each procedure after the initial catheterisation. Enter modifier
                            6305 on line 6 under the heading “dt-from” to instruct the system to calculate the reduced fee. The first
6305        Modifier code   catheterisation is charged at 100% of the unit value.




                                                                                                                                         21     06/05/11
                                       List of dental modifiers – 2002

            How to
Modifier    apply                                                       Explanation                                                            Value
                           The fee for a Specialist Dental Assistant is 33.33% of the benefit payable to the specialist dental
                           surgeon. For multiple procedures, first use memory code 80008 on line 6 to link every procedure for
                           which the assistant must be paid. Then use memory code 80008 as the tariff code and modifier 8001
8001       Modifier code   on line 6 under the heading “dt-from” to instruct the system to calculate the specialist assistant’s fee.

                           An additional 50% of the applicable benefit payable to Maxillo-facial and Oral surgeons when they quote
                           tariff codes that appear in the G P dentists’ section of the gazette. Add the fees charged for the
                           procedure and modifier 0002 together and enter modifier 8002 on line 6 under the heading “dt-from” to
8002       Modifier code   instruct the system to calculate the additional fee.

8003       Deleted

                           General dental practitioners may only quote tariff codes for specialists when the appropriate service is
                           not listed in their section of the gazette – when they do quote modifier 8004, the benefit will be 2/3 (two-
                           thirds) of the specialist’s fee. The system will calculate the 2/3 of the specialist’s benefit
8004       Informational   programmatically, therefore modifier 8004 must be ignored and NOT used when assessing.




                                                                                                                                          22     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                         Value
                            When more than one operation or procedure is performed through the same incision, the fee shall be
                            100% of the BHF/SADA tariff for the major (most expensive) operation/procedure and a maximum of
                            R146.30 (BHF) for each subsidiary operation/procedure performed. Enter modifier 8005 on line 6 under
8005        Modifier code   the heading “dt-from” for every applicable line to instruct the system not to pay more than R146.30.       BHF: R 146.30

                            When more than one operation or procedure is performed under the same anaesthetic, but through
                            different incisions, the fee shall be 100% of the BHF/SADA tariff for the major (most expensive)
                            operation/procedure plus 75% of the BHF/SADA tariff for the second operation/procedure (modifier
                            8009) and 50% of the BHF/SADA tariff for the third operation/procedure (modifier 8006). Enter modifier
                            8006 on line 6 under the heading “dt-from” for the appropriate claim line, to instruct the system to
8006        Modifier code   calculate 50%.

                            The fee for a General Practitioner (GP) Dental Assistant is 15% of the benefit payable to the
                            practitioner performing the operation(s). First use memory code 80008 on line 6 to link every procedure
                            for which the assistant must be paid. Then use memory code 80008 as the tariff code and modifier
                            8007 on line 6 under the heading “dt-from” to instruct the system to calculate the GP dental assistant’s   Minimum fee –
8007        Modifier code   fee.                                                                                                       BHF: R 94.30

                            The additional fee to all members of the surgical team for after hours emergency surgery shall be 25%
                            of the applicable benefit payable for the procedure or procedures performed. Enter modifier 8008 on
                            line 6 under the heading “dt-from” for every applicable line to instruct the system to calculate an
                            additional 25%.
                            An additional 25% is also payable when procedures 8361 to 8374 are performed and the applicable
                            laboratory fees are NOT charged. Add the fees charged for the procedure and modifier 8008 together
                            and enter modifier 8008 on line 6 under the heading “dt-from” for the applicable line to instruct the
8008        Modifier code   system to calculate an additional 25%.




                                                                                                                                        23     06/05/11
              How to
 Modifier      apply                                                      Explanation                                                         Value
                            When more than one operation or procedure is performed under the same anaesthetic, but through
                            different incisions, the fee shall be 100% of the BHF/DASA tariff for the major (most expensive)
                            operation/procedure plus 75% of the BHF/DASA tariff for the second operation/procedure (modifier
                            8009) and 50% of the BHF/DASA tariff for the third operation/procedure (modifier 8006). Enter modifier
                            8009 on line 6 under the heading “dt-from” for the appropriate claim line, to instruct the system to
8009        Modifier code   calculate 75%.

                            An additional 75% of the fee is payable when open reduction is required for tariff codes 9035 and 9037.
                            Add the fees charged for the procedure and modifier 8010 together and enter modifier 8010 on line 6
8010        Modifier code   under the heading “dt-from” for the applicable line to instruct the system to calculate an additional 75%.




                                                                                                                                         24     06/05/11
                                   List of auxiliary modifiers – 2002

            How to
Modifier    apply                                                      Explanation                                                            Value
                           Discipline 39 – Radiographer
                           A call-out fee of R25.40 is payable for any bona-fide, justifiable emergency occurring at any hour which
                           requires the practitioner to travel to the patient. Motivation must be attached. Use modifier 0001 as the
0001       Tariff code     tariff code to pay the call-out fee.                                                                         BHF: R25.40
                           Discipline 39 – Radiographer
0080       Informational   When multiple examinations are performed, 100% of the BHF tariff is payable for each examination.
                           Discipline 39 – Radiographer
0081       Informational   When repeat examinations are performed, 100% of the BHF tariff is payable for each examination.
                           Discipline 39 – Radiographer
                           An additional benefit payable to the practitioner for the cost of the film that is used to take the X-ray.
                           Enter modifier 0084 on line 6 under the heading “dt-from” to instruct the system to calculate the fee for
0084       Modifier code   the cost of the film.




                                                                                                                                         25     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                         Value
                            Discipline 66 – Occupational therapist
                            Materials used for the manufacturing of orthoses* or pressure garments. Use the Inhouse tariff code
                            66009 to assess the fees charged for modifier 0009.
                            *orthosis (singular) = a force system designed to control, correct or compensate for a bone deformity or
0009        Informational   forces absent from the body. Orthosis often involves the use of special braces.
                            Discipline 66 – Occupational therapist
                            Other materials used during the treatment. Use the Inhouse tariff code 66010 to assess the fees
0010        Informational   charged for modifier 0010.
                            Discipline 66 – Occupational therapist
                            A charge by the occupational therapist for travelling expenses which is payable on the Open Plan
                            options. Use the Inhouse tariff code 66011 to pay for the travelling expenses.
                            Note: Where, in cases of emergency, a practitioner was called out from his residence or rooms to a
                            patient’s home or the hospital, travelling fees may be charged for if he had to travel more than 16
0011        Informational   kilometres in total.

                            Discipline 68 – Podiatrist
                            When procedures 68021 to 68031 are carried out in a day clinic or unattached operating theatre unit, the
                            benefit shall be reduced to two-thirds. Add the fees charged for the procedure and modifier 0002
                            together. Enter modifier 0002 on line 6 under the heading “dt-from” for every applicable line to instruct
0002        Modifier code   the system to calculate only 2/3 of the applicable benefit.
                            Discipline 68 – Podiatrist
0004        Informational   An indication that treatment was performed in a nursing facility or hospital.




                                                                                                                                        26     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                           Value
                            Discipline 72 – Physiotherapist
                            An appointment not kept by the patient does not qualify for benefits. Reject the charge for the
                            appointment not kept with rejection code 201: “No benefits on this type of service”. Use modifier 0001
0001        Tariff code     as the tariff code to reject the charge for the appointment not kept.
                            Discipline 72 – Physiotherapist
                            For the use of equipment not owned by the physiotherapist – only pay 85% of the relevant fee. Add the
                            fees charged for the procedure and modifier 0003 together. Enter modifier 0003 on line 6 under the
                            heading “dt-from” for every applicable line to instruct the system to calculate only 85% of the applicable
0003        Modifier code   benefit.
                            Discipline 72 – Physiotherapist
                            An additional 50% is payable for each emergency treatment performed at any hour which requires the
                            practitioner to travel to the patient or the place of treatment. Add the fees charged for the procedure and
                            modifier 0006 together. Enter modifier 0006 on line 6 under the heading “dt-from” for every applicable
0006        Modifier code   line to instruct the system to calculate an additional 50%.
                            Discipline 72 – Physiotherapist
                            Only pay 50% of the relevant fee for each additional procedure performed at the same consultation or
                            visit for the same condition. First pay 100% of the BHF tariff or Cost for the most expensive procedure
                            and then apply modifier 0008 to the two additional procedures to pay 50%. Enter modifier 0008 on line
                            6 under the heading “dt-from” for every applicable line to instruct the system to calculate only 50% of the
0008        Modifier code   applicable benefit.




                                                                                                                                          27     06/05/11
              How to
 Modifier      apply                                                    Explanation                                                         Value
                            Discipline 72 – Physiotherapist (continued)
                            When more than one condition requires treatment and each condition necessitates INDIVIDUAL
                            treatment time – pay the full relevant benefit for each condition. Assess the lines applicable to the
                            second condition in the same manner as for the first condition. First pay 100% of the BHF tariff or Cost
                            for the most expensive procedure and then apply modifier 0009 to the two additional procedures to pay
                            50%. Enter modifier 0008 on line 6 under the heading “dt-from” for every applicable line to instruct the
0009        Informational   system to calculate only 50% of the applicable benefit.
                            Discipline 72 – Physiotherapist
                            When more than one condition requires treatment and the treatment time OVERLAPS – only pay 50%
                            of the relevant fee for the second condition. Pay the first condition as per modifier 0008. For the
                            second condition, first apply modifier 0010 to pay 50% of the BHF tariff or Cost for the most expensive
0010        Modifier code   procedure and then apply modifiers 0008 and 0010 to the two additional procedures to pay 25%.
                            Discipline 72 – Physiotherapist
                            A fee charged by the physiotherapist for travelling expenses which is payable on the Open Plan options.
                            Use modifier 0013 as the tariff code to pay for the travelling expenses.
                            Note: Where, in cases of emergency, a practitioner was called out from his residence or rooms to a
                            patient’s home or the hospital, travelling fees may be charged for if he had to travel more than 16
0013        Tariff code     kilometres in total.
                            Discipline 72 – Physiotherapist
0014        Informational   An indication that treatment was rendered to an in-patient in a nursing home or hospital.




                                                                                                                                       28     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                          Value
                            Discipline 75(9) - Biokenitician
                            An appointment not kept by the patient does not qualify for benefits. Reject the charge for the
                            appointment not kept with rejection code 201: “No benefits on this type of service”. Use modifier 0001
0001        Tariff code     as the tariff code to reject the charge for the appointment not kept.
                            Discipline 75(9) - Biokinetics
                            When more than one condition requires treatment and each condition necessitates INDIVIDUAL
0008        Informational   treatment time – pay the full relevant benefit for each condition.
                            Discipline 75(9) - Biokinetics
                            When more than one condition requires treatment and the treatment time OVERLAPS – only pay 50%
                            of the relevant fee for the second condition. Enter modifier 0009 on line 6 under the heading “dt-from”
0009        Modifier code   to instruct the system to calculate the 50% for the second condition.

                            Discipline 80 - Registered Nursing Agency
                            The fee in respect of more than one procedure performed at the same time shall be the fee in respect of
                            the major procedure plus R17.60 in respect of each subsidiary or additional procedure. Use modifier
0001        Tariff code     0001 as the tariff code to pay for each subsidiary or additional procedure.                                 BHF: R 17.60
                            Discipline 80 - Registered Nursing Agency
                            The fee that may be charged in respect of the rendering of a service not listed in this recommended
                            benefit schedule shall be based on the fee in respect of a fee for a comparable service. Motivation
0002        Informational   must be attached.
                            Discipline 80 - Registered Nursing Agency
                            In cases where the fee is disproportionately low in relation to the service rendered, a higher fee may be
0003        Informational   negotiated with the scheme. Motivation must be attached.




                                                                                                                                         29     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                          Value
                            Discipline 86 – Clinical Psychologist
                            When first or subsequent consultations proceed into or are immediately followed by a psychotherapeutic
                            procedure, fees for the procedure are calculated according to tariff codes 86041 or 86051 or 86061 or
                            86018 for a 20-minute session or part thereof, provided that such part comprises 50% or more of the
0001        Informational   time of a session.
                            Discipline 86 – Clinical Psychologist
                            An additional 50% is payable to the psychologist for having to go to the hospital or clinic to treat the
                            patient. Add the fees charged for the procedure and modifier 0002 together. Enter modifier 0002 on line
                            6 under the heading “dt-from” for every applicable line to instruct the system to calculate an additional
0002        Modifier code   50%. Applicable to tariff codes 86001 to 86045.

                            Discipline 86 – Clinical Psychologist (continued)
                            An additional 50% is payable for each emergency psychological procedure performed at any hour which
                            requires the practitioner to travel to the patient or the place of treatment. Add the fees charged for the
                            procedure and modifier 0003 together. Enter modifier 0003 on line 6 under the heading “dt-from” for
                            every applicable line to instruct the system to calculate an additional 50%. Motivation must be
0003        Modifier code   attached. Modifier 0003 may NOT be used in conjunction with modifier 0004.
                            Discipline 86 – Clinical Psychologist
                            An indication that treatment was rendered to an in-patient in a nursing home or hospital. Modifier 0004
0004        Informational   may NOT be used in conjunction with modifier 0003.




                                                                                                                                         30     06/05/11
              How to
 Modifier      apply                                                     Explanation                                                          Value
                            Discipline 88 – Private Nurses
                            The fee in respect of more than one procedure performed at the same time shall be the fee in respect of
                            the major procedure plus R17.60 in respect of each subsidiary or additional procedure. Use modifier
0002        Tariff code     0002 as the tariff code to pay for each subsidiary or additional procedure.                                 BHF: R 17.60
                            Discipline 88 – Private Nurses
                            The fee that may be charged in respect of the rendering of a service not listed in this recommended
                            benefit schedule shall be based on the fee in respect of a fee for a comparable service. Motivation
0003        Informational   must be attached.
                            Discipline 88 – Private Nurses
                            In cases where the fee is disproportionately low in relation to the service rendered, a higher fee may be
0005        Informational   negotiated with the scheme. Motivation must be attached.
                            Discipline 88 – Private Nurses
                            Only 50% of the fee is payable when tariff code 88100 is charged as a subsequent procedure. Enter
                            modifier 0006 on line 6 under the heading “dt-from” for every applicable line to instruct the system to
0006        Modifier code   calculate only 50% of the relevant fee.




                                                                                                                                         31     06/05/11

				
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