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Circular 47 of 2022: PMB Coded List

The Council for Medical Schemes (CMS) would like to bring to your attention the publication of the new PMB Coded List. Clinical Review Committee members have established that the 2013 PMB and ICD-10 Coded List needs to be updated to include previously omitted ICD-10 codes and COVID-19.

  1. Annexure A of the General Regulations made in terms of the Medical Schemes Act, 131 of 1998 provides a schedule of “diagnosis and treatment pairs”, which cumulatively comprise the prescribed minimum benefits (PMBs) to be provided to beneficiaries of medical schemes in terms of section 29(1)(o) of the Act.
  2. In the event of conflict between this interpretation and the definition of conditions set out in Annexure A to the regulations, the definition of conditions contained in the regulations will prevail.
  3. The codes in this guideline may be associated with the cause of the condition or may describe a functional state. The inclusion of the code here does not imply that the condition automatically qualifies for prescribed minimum benefits. These codes only serve to assist in the identification of possible PMB conditions. To qualify as a PMB condition, the condition must fully meet the criteria in the PMB descriptor.

The changes are implemented with immediate effect. The updated PMB Coded List can be found here, along with a summary of changes made to the list here.

Download the Circular here.