CMScript 10 of 2024: Coding and funding of claims

Coding in healthcare is a simple, standardised system for recording and sharing information about medical conditions, treatments, and services. Instead of long medical terms, this system uses short codes that are universally recognised and specific to different diseases and treatments.

Accurate coding helps the healthcare industry bill, process and pay claims, track health trends, and improve patient care. It also helps maintain proper health records and makes the administration process smoother. Coders must stay updated on the latest rules and changes to keep systems running correctly.

Types of coding systems used in South Africa

1. International Classification of Diseases (ICD) were developed by the World Health Organization (WHO). ICD codes are used to describe the patient’s signs and symptoms, and diagnosis or reason for seeing a healthcare provider. They contain both letters and numbers that healthcare providers and medical schemes use to communicate about the health issue being treated. These codes also help medical schemes to decide how a condition should be covered or funded. They enable the consistent recording, analysis, interpretation, and comparison of health information about illnesses and causes of death. The 10^th ICD (ICD-10) version is currently used in the country. An example of an ICD-10 code is “J45.9” which refers to “Asthma, unspecified”.

2. National Reference Price List (NRPL) coding is used to inform medical schemes about the services that were provided to a member so that claims can be settled correctly. The purpose of the procedure/item codes is to convert the description of services into specific codes. Various healthcare disciplines, such as doctors, nurses, and physiotherapists, have their own unique set of codes that describe the specific services they can charge. An example of a four-digit NRPL tariff code is “1101”, which refers to “Tonsillectomy (dissection of the tonsils)”, usually performed by an Ear, Nose and Throat (ENT) Specialist.

3. Current Procedural Terminology (CPT®) codes were developed by the American Medical Association (AMA) to describe medical, surgical, and diagnostic services. These five-digit codes help medical professionals and medical schemes clearly communicate about the treatments or services the patients receive. The South African Medical Association (SAMA) publishes an annual version of the Complete CPT® for South Africa (CCSA) codes. An example of a CCSA code is “99199”, which is used for “unlisted special services, procedures, or reports”.

4. Uniform Patient Fee Schedule (UPFS) codes are used in the public sector to standardise payment rates for various medical services and procedures. An example of a UPFS code is “2511”, which refers to “Outpatient Consultation – General medical practitioner”.

5. National Pharmaceutical Product Interface (NAPPI) codes are used to identify pharmaceutical products, including medicines and medical devices. These codes have nine digits. The first six digits of a NAPPI code identify the product/medicine, and the last three digits indicate the pack size. For example, a NAPPI code for “Corsodyl mint mouthwash (0,2%)” is “808377”. These codes are essential for the billing and dispensing of medications.

Read more on the latest CMScript on Coding available here