- 1. Application forms: All submissions MUST be made on the appropriate application forms (changes, discontinued, or additions) forms - the forms are also available on the SAMA website (https//www.samedical.org/ Home >> Private Practice >> Coding >> MDCM Medical Code Submissions
- 2. Supporting CPT® codes: All new codes to be considered must be supported by a valid CPT® code or range of codes.
Please note that if a range of codes are supporting the submission and accepted for introduction to the MDCM, the full range of codes will be added to the MDCM and not just one or two codes from that range.
- 3. No CPT® codes available: If CPT® codes are not available, full motivation must be supplied including:
- (1) An adequate definition or description of the nature, extent and need for the procedure/service or "medical necessity";
- (2) In which respect is this service unusual or different in technique, compared to available procedures/services listed in the coding structure? Information regarding the nature and extent of the procedure/service, time and effort, special/dedicated equipment needed to provide this service, must be included in the report;
- (3) Is this procedure/service medically appropriate under the circumstances? Explain why another procedure/service listed in the coding structure will not be appropriate in this case;
- (4) A description of the complexity of the symptoms and concurrent problems must be supplied;
- (5) Final diagnosis supported by the appropriate ICD-10 code(s);
- (6) Pertinent physical findings (size, location and number of lesions, if applicable);
- (7) Make mention of any other diagnostic or therapeutic procedure(s)/service(s) provided at the same session;
- (8) Any further diagnostic or therapeutic procedure(s)/service(s) to be provided in the follow-up period; and
- (9) Description of the follow-up care needed.
This code will have a Z indicator in the far left column of the tables – refer to the information about Z indicator in this document.
Please note that where new information about CPT® codes and/or RVUs becomes available the code in the MDCM will be amended taking this information into consideration. The Group/Discipline that applied for this code will be informed accordingly. Please note that the RVUs might go up or down. This was agreed at the SPPC meeting held in May 2018.
- 4. Baseline for unit allocation: The RVUs from the latest edition of the Complete CPT® for South Africa publication will be used for all new submissions based on CPT®
- 5. Conversion factor: The RVUs allocated to the CPT® code will be multiplied by 10 to get to the SAMA units. The Facility Total RVUs will used as the baseline (even though some procedures may be performed in a non-facility setting). Thus the conversion factor of CPT RVUs to SAMA units will be 1 RVU:10 units.
- 6. Special equipment: All special equipment codes will each have to be costed and utilisation, purchase cost and all other expenses directly related to the equipment should be calculated to motivate for SAMA units. Special equipment does not form part of the usual equipment used in rooms which forms part of the practice cost. The RVUs reflected in the Resource Based Relative Value Scale (RBRVS) will not be used as is since the cost of equipment differs from that used in South Africa since most of the equipment in imported from other countries.
The “T” indicator in the far left column of the tables is only allocated to new equipment codes based on CPT® or CPT® code equivalent codes where the cost of equipment differs from that used in South Africa. Therefore values will have to be negotiated by the discipline utilising the item.
- 7. Guidelines, interpretations and/or comments: All disciplines must supply SAMA with clinical guidelines, interpretations and/or comments for the different codes used by their discipline - these guidelines should reach the SAMA Coding Department by a date to be determined on an annual basis - usually before middle of May of the year the submission is considered.
- 8. Presentations to be made: All submissions must be motivated for in person at the Private Practice Committee meeting at a date to be determined by the Committee, otherwise the submissions will not be considered.
- 9. The Private Practice Committee will after careful consideration of submissions take one of the following decisions:
- a. Accept the submission for new, revised or discontinued codes; or
- b. Reject the submission for new or revised codes - reasons to be supplied; or
- c. Referred back to the discipline/group for example to supply more information
- 10. Same code used by different disciplines/groups: A code in a specific section does not mean that the code can only be used by the discipline most commonly using codes from that section. It is not possible to add duplicate codes to the coding structure because more than one discipline would use the code, therefore practitioners should not be penalised if codes outside their common code list is used for services rendered.
Removal of duplicate codes: Duplicate codes from the current structure will have to be scrapped. Submissions for the deletion of one of the duplicate codes must be made on the appropriate submission form.
- 11. Z indicator:
- The “Z” indicator in the far left column of the tables is only allocated to new codes not based on CPT® or CPT® code equivalent codes without RVUs. Where new information about CPT® codes and/or RVUs become available the code in the MDCM will be amended taking this information into consideration. The Group/Discipline that applied for this code will be informed accordingly. Please note that the RVUs might go up or down. This was agreed at the SPPC meeting held in May 2018.
- Items marked with a "Z" indicator are items which have to be reviewed at set dates, e.g. 6 months, 1 year, and 2 years after the utilisation data was processed. The Groups using these items must provide audited utilisation and cost figures for a future correction of the usage fee to the Medical Coding Division of the SAMA Private Practice Department on email@example.com before the end of January each year. Should such utilisation and costs data not be supplied by the Group, the usage of this item may be discontinued.
- The “Z” indicator does not imply that medical schemes will not provide benefits for these items. It depends entirely on their benefit structure
- 12. T indicator: Temporary codes are marked with a “T” in the far left column of the tables where the utilisation of the item is not calculated with regards equipment. Therefore values will have to be negotiated by the discipline utilising the item.
- 13. Descriptions to be used in MDCM: The latest edition of the Complete CPT® for South Africa (at this stage CCSA2020) code descriptors will be used as base descriptors for all new codes or codes where revised descriptors are required. However, the descriptions of the codes to be added or amended for the MDCM may not have exact CPT® descriptors and will have to be amended to reflect the same information but not the exact same wording (copyright of AMA information must be taken into consideration).
- 14. Introduction to MDCM: All accepted submissions, unless otherwise decided by the Committee, will be introduced in the second year after the submissions were made.
- 15. Scope of practice reflected: The scope of the different disciplines should be reflected in the Medical Doctors' Coding Manual and not just those codes medical schemes may consider granting benefits.
- 16. Relationships with other groups/disciplines: Please note that if use of the procedure/service overlaps with other groups it is essential that these groups be contacted to negotiate common intent and purpose
(Kindly note that separate forms are available for equipment and pathology requests. Please contact the SAMA Medical Coding Division on firstname.lastname@example.org)
NOTE: Closing date to receive the final 2021 MDCM submissions is on 24 January 2020
Please note that all submissions must reach the SAMA Medical Coding Division as soon as possible to give the staff an opportunity to double check the information and to ensure that only the final submissions are considered by the Specialist Private Practice Committee at the first meeting of 2020 (end February 2020)
Submission forms (above) have to be completed correctly and completely. No late submissions will be accepted. Contact the SAMA Medical Coding Unit (email@example.com) for assistance if required.
Late submissions will only be considered and incorporated into the 2022 Medical Doctors' Coding Manual.