In follow up to the November 2010 “Appropriate billing” letter (20101111 billing letter to practices 2010.pdf), the following have since been brought to my attention:
- There are still practices that do all, or virtually all MRI brain studies, pre-and post contrast. This falls far outside the norm in South Africa where the incidence of contrast MRI Brain studies is approximately 20-25% of all brain studies done and is also far outside the norms supported by international practice standards.
- In spite of the plea for circumspection when it comes to the billing of brain plus diffusion studies, there are still practices where this is billed in virtually every MRI study of the brain performed in these particular practices.
- In spite of all the concerns regarding unnecessary radiation exposure, over and above the unnecessary costs incurred, there are still practices where triphasic studies of the abdomen and liver are used as the routine CT examination study of the abdomen.
- The venous Doppler code for DVT is: 70230. However, there are practices whom persist in using 70240 for DVT cases. The use of code 70240 is limited to cases where vein mapping for donor venous grafts or for planning of varicose vein surgery, where perforators need to be identified, is required. There are once again a few practices whom persist in using 70240 for all venous Doppler studies.
- As was previously explained in the November 2010 note, code 20220 is the designated code for arterial studies of the neck (carotid Doppler) which includes evaluation both of the carotid and vertebral arterial systems, specifically in suspected atherosclerotic disease. The use of code 20230 is limited to cases where pre-surgical or pre-interventional procedure evaluation of the extra-cranial vasculature in cases of trans-dural vascular malformations, is required.
- Code 40110 (chest + erect and supine abdomen) has become the routine study of the abdomen in some practices where the clinical request is only to exclude or confirm the presence of faecal loading or urinary tract stones. A single abdominal view is adequate in the vast majority of these cases.
- Code 30120 (chest + additional views) is also becoming the routine in some practices where a chest X-ray is requested. If an extra view to see the bases or the apices is required because the Radiographer cut either of these off on the initial film, or the patient is tall, this does not qualify as an additional view. The additional view code is only to be used for decubitus views and in the few cases where dedicated apical or reverse apical views are required.
I am constantly consulted by the medical advisors and the administrators of various funders regarding the above practice specific behavior patterns, which fall well outside the norm and which I cannot defend on any clinical grounds.
Please read the code of conduct section on the RSSA website: www.rssa.co.za We should all try to practice according to these principles where the interest of the patient comes first and last in all respects.
I am aware that local conditions vary from site to site and these influence the method of practice at a particular site. I am not aware of any justifiable circumstances that necessitate the exceptional variation in billing patterns, when compared to the rest of the country, or the insistence to bill for codes outside of their intended use. If funders decide to treat these practices differently regarding payment or to advise their patients not to use these practices, i.e. black list these practices, I will have no grounds to challenge their decisions.