Minimum Requirements for Coding & Tariff Determination of New Technology - Casper Venter Director HealthMan (Pty) Ltd Medical Devices and Health Technology Assessment: Resolving the Puzzle
Market inquiry focus (draft) Hospitals Medical Schemes Administrators and Managed Care Organisations Specialists General Practitioners Market inquiry focus (revised) Medical devices and Pharmaceutical industries Integrity of the regulatory framework acknowledged and incorporated
Market inquiry focus on Specialists & GPs The How? of Tariff setting and the role of industry reference lists GPs as gatekeepers; referral processes and relationships with Hospitals and Specialists Hospitals; relationships with GPs and Specialists, incentives and access to operating facilities HPCSA Rules- promotional activities and employment of Doctors by Hospitals Alternative Reimbursement Models (ARMs)
Lack of an Authoritative Reference Source for new codes & queries Code Manipulations and billing malpractice exist and on the increase Certain procedures in the past were described by one or two codes with a few additional codes for the complicated case. Now routinely being used and more codes added. Guidelines established are not freely available, RPL does not exist, however many Schemes still use 2006 NHRPL, especially in Forensic Reviews Unilateral decision making process by Schemes and Providers Lack of transparency Not all providers support the structure in place Determination of RVU values Lacks transparency and outdated Review of existing RVU values- Top 300 review New technology/techniques Use of existing codes and adding others to make up fee Unnecessary motivations required No guidance on how to set new codes or RVUs Cannot set a Tariff!! Only a RVU, but no Crosswalk for RVUs
Let s look at some of the statistics that generate medical services invoices
Code Analysis: Percentage by Value Specialist Payments- 2013 Data (Consulting & Surgical) Code Percentage (%) Consultations 29.73% Modifiers 7.67% Materials 3.31% Procedures & Equipment 59.29%
24 Codes comprise 50.34% 100 Codes comprise 74.92% 200 Codes comprise 85.15% 300 Codes comprise 90.26% 490 Codes comprise 95.01% 2 372 Codes comprise 100.00%
Rank Code Type Code % Utilised 1 2974/5 Psychotherapy 3.39 2 2615 Obstetrics Caesarean 2.87 3 3047/9 Cataract 1.65 4 1210 ICU Multiple Organ Failure 1.62 5 5100 Ultrasound 1.50 6 1206 ICU Category 2 1.17 7 1653 Total Colonoscopy 1.09 8 3622 Cardiac Examination 1.06 9 2614 Obstetric Normal Delivery 1.02 10 1235 Multistage treadmill 0.98 11 0614 Arthroplasty: Debridement Joints 0.93 12 1587 Upper Gastro Endoscopy 0.83
Codes Discipline 1 25 Cardiology 2 4 Cardio Thoracic 3 17 ENT 4 30 Gynaecology 5 17 Ophthalmology 6 69 Neuro Surgery & Orthopaedics 7 8 Neurology 8 3 Psychiatry 9 52 Surgery 10 25 Urology 11 20 Pulmonology 12 22 Consultations/ E & M Codes
Code Descriptor RVU Frequency Practices Amount 0201 Medicine & Materials - 2,490,815 2 775 5100 Pelvic Sonar 50 359,550 729 1235 Multi-stage Treadmill 60 155,615 448 3202 Phako emulsification apparatus: Hire 3615 Routine Obstetric Ultrasound, 10 20 weeks 3009 Basic Capital Equipment used in own rooms by Ophthalmologist 3617 Routine Obstetric Ultrasound, 20 24 weeks 109 46,560 241 110 84,555 651-332,650 305 50 65,340 558 390,229,790 216,385,898 130,250,328 77,852,738 51,526,278 51,276,268 40,340,935
Code Descriptor RVU Frequency Practices Amount 1019 ENT Endoscopy in Rooms 12 62,200 207 10,324,448 1259 Pacemaker: Permanent: Dual Chamber 3201 Laser apparatus (Ophthalmic): Hire 230 2,030 130 6,893,260 150 24,603 249 37,811,693 3203 Vitrectomy apparatus: Hire 120 4,828 104 8,903,388 3627 Ultrasound examination include whole abdomen 60 24,850 186 19,335,850 5102 Ultrasound of joints 50 11,250 51 6,043,428
Coding Application Process Submissions Stakeholders SAPPF/SAMA office Specialty Assoc. Publish New Codes Review & Prepare Documents Technical Committee Reviews Joint Coding Meetings Funding Industry
Descriptor Fee RVU CPT Code Ambulatory, Continuous Glucose Monitoring of interstitial tissue fluid via a minimum of 72 hours SA Code R549 48.9 95250 4168 Interpretation and report of Ambulatory, Continuous Glucose Monitoring R137 Or R222 12.5 95251 4169 Consultation Scheme Rate (RCF) R 17.780 Procedure Scheme Rate (RCF) R 11.012
Diagnostic Equipment Cost Price R 4 550 000 (Ex VAT) Prime Overdraft Rate 9.5% ROI 4.5% (above Prime) Ammortisation 5 years Maintenance 2% per year Insurance 1% per year Utilisation per Practice 40% Average minutes 48 000 minutes Number of Sites in SA 150 Procedure Time 15 to 45 minutes Annual Utilisation 19 500 procedures
Results (Ex VAT) Ammortization Costs R 1 598 340.00 Equipment overhead rate per minute R 33.30 Professional labour rate per minute R 15.13 Mammography labour per minute R 3.43 Cost Based on Minutes R 1 572.00 Imaging RCF @ Scheme Rate R 13.30 Relative Value Units?? 118 RVUs Previous RVUs 50 RVUs
CUSTODIAN SOUTH AFRICAN CLASSIFICATION FOR HEALTH INTERVENTIONS ( SACHI ) DIAGNOSTIC CODING PROCEDURAL CODING DRG S ICD - 10 ADVISORY COMMITTE EDITORIAL PANEL RELATIVITIES COMMITTEE COST COMMITTEE POLICY COMMITTEE DESCRIPTORS STANDARDS, STATISTICAL IMPACT CODING AND CLINICAL RULES TIME PRACTICE COST LIAISON, STATE LIAISON, OUTCOMES CODING CONSULTANT RESPONSIBILITY FINANCIAL CONSULTANT HEALTH TECHNOLOGY ASSESSMENT CODING CONSULTANT COMPLEXITY GEOGRAPHICAL FACTOR ACTUARIAL CONSULTANT SCARCE SKILLS
The Way Forward Maintenance of current coding structures lacks a governance structure Involve all Professions and Stakeholders South African Classification of Healthcare Interventions (SACHI) Take control of the governance process Maintain custody of coding structures within professional societies Urgency! Co established and MOI being drawn up