NAMIBIAN BENCHMARK TARIFF IN RESPECT OF PHYSIOTHERAPISTS WITH EFFECT FROM 1 JANUARY 2017

Transcription

1 NAMIBIAN BENCHMARK TARIFF IN RESPECT OF PHYSIOTHERAPISTS WITH EFFECT FROM 1 JANUARY 2017 THIS SCHEDULE IN NO WAY CONSTITUTES AN AGREEMENT BETWEEN ANY PARTIES. ALL BENCHMARK TARIFFS ARE INCLUSIVE OF VAT A physiotherapist is a healthcare practitioner registered as a Physiotherapist with the Allied Health Profession's Council of Namibia in terms of the Allied Health Profession's Act, 2004 (Act No. 7 of 2004). REGULATIONS DEFINING THE SCOPE OF THE PROFESSION OF PHYSIOTHERAPY Acknowledgement is given to all the participants for their co-operation and assistance in supplying the relevant schedule published hereunder: In terms of relevant legislation applicable in Namibia, regulations set out in the Schedule hereto were made: Schedule 1 The following acts are hereby specified as acts which shall for the purposes of the Act be deemed to be acts pertaining to the profession of physiotherapy. These acts shall be performed in the following fields covered by physiotherapy as a supplementary service to medicine: a Orthopaedics: In the whole field of orthopaedics, as requested by the medical practitioner. This includes fractures, dislocations, ligamentous and soft tissue lesions, joint deformities and diseases, infections of bone, including those of the spine, and their complications, amputations, specialised branches, e.g. hand surgery and tendon and muscle transplants. b Neurology and Neurosurgery - including participation by the physiotherapist in intensive care and rehabilitation. c Respiratory diseases and thoracic surgery - Including inhalation therapy and participation by the physiotherapist in intensive care. d Cardio-vascular diseases and surgery e Obstetrics and Gynaecology - Including pre-operative and post-operative surgical conditions, antenatal and post-natal instruction, pelvic infections and other gynaecological conditions. f Intensive Care Units - Including coronary care, organ transplantation, dialysis, respiratory failure, tetanus, extensive paralysis, unconsciousness, accent services (multiple injuries) and burns. g Rehabilitation of the patient to his maximum potential both in work and sport, including adaptation to permanent disabilities. h Sport medicine which includes prophylaxis and the treatment of all injuries and disabilities directly pertaining in sport. i Paediatrics including all related field, of medicine and surgery, including cerebral palsy; care of children with minimal brain dysfunction; developmental abnormalities; the prevention of orthopaedic and postural deformities. j Geriatrics - including the care of the aged in all related fields of medicine and surgery; prophylaxis; rehabilitation and recreational activities. k Treatment of physical ailments of psychiatric patients; relaxation therapy; maintenance or restoration of physical fitness; organisation of remedial games, sports and recreational activities. l Other surgical fields - including general, plastic, urological, maxillo-facial, ophthalmological, ear, nose and throat, and other surgical fields that may require physiotherapy services. m Other medical fields - including rheumatology, dermatology, ear, nose and throat fields, constitutional fields, Hansen's disease, cancer and any other medical fields that may require physiotherapy services. n Community care - including prophylactic physiotherapy services, district and domicilliary services, day hospital organisations, rehabilitation centres including schools, industries and others. 1 The scientific use of movement techniques based upon physiological principles, supplemented when necessary by massage, manipulation, electrotherapy and other physical and supportive measures and including advice to, and education of, the patient, for the prevention and treatment of injury, disease and disorders, and the facilitation of normal physiological processes and functional activities. These are used to assist rehabilitation and restoration of function, including the achievement of personal independence. 2 The use of the following procedures in the fields covered by physiotherapy as a supplementary service to medicine: a Physiotherapeutic examination of patients according to the condition diagnosed by the medical practitioner or dentist, including continuous assessment of the patient's response to physiotherapy treatment and of progress made. Such examination includes the assessment of joint range; muscle power, strength, tone, endurance and co-ordination, righting, balance and equilibrium reactions; postural abnormalities, functional ability, the need for rehabilitation and degree of independence attained; the level of sensory and motor development, circumference, length (e.g. of the leg), volume, excursion and other relevant measurements; the effects of pain on movement, rest and function; gait abnormalities and other locomotor abnormalities; physical fitness tests; cardiac (exercise) tolerance tests; respiratory excursion and exercise tolerance tests and measurements; sensory tests, including stereognosis; perception, tests, observation; palpitation, inspection of X-rays and X-ray reports, skin temperature and condition,, the effects of soft tissue scars, adhesions and contractions on movements and functions; nerve conduction and innervation tests; reflex heating tests requirements for the use of artificial limbs, prostheses, aids, appliances, callipers, splints, supports, corsets, collars, etc: the need for the use of wheelchairs, and any other special tests or methods of assessment by physiotherapy that may be required for the management of patients and for the submission of reports to the medical practitioner or dentist. b Selection of treatment techniques and supportive devices according to the diagnosis given by, and in consultation with, the referring medical practitioner or dentist, based on the results of the examination referred to in 2(a) above and in conjunction with other registered supplementary health services personnel concerned with the treatment, management and/or rehabilitation of the patient. These include any of the procedures detailed below, as well as advice on the selection of wheelchairs and on the selection or making of permanent or temporarily prostheses, aids, appliances, splints, callipers, supports, collars, corsets, walking aids or any other physiotherapeutic device or method which may be required.

2 c Education of, and advice to, the patient or those responsible for his care, according to the condition diagnosed by, and in consultation with, the referring medical practitioner or dentist or any other personnel concerned with the care of the patient. These include prophylactic physiotherapy, prevention of joint and muscle strain and back strain, advice on the lifting and handling of patients and heavy objectives, prevention of recurrence of mechanical disorders; function al activities, rest positions and working postures, recreational and sport activities, kinetic handling in industry, education for childbirth; the handling of disabled persons in hospital, at home, at work and during transport, recreational and sports activities; care and handling of the aged, children and infants, the use of respirators; postural drainage in hospital or at home, advice on the use of aids and appliances referred to above; and any other advice concerning the physiotherapy field which may be required. 3 The giving of the following movement and exercise therapy (i.e. the application of kinesiological and neurophysiological principles): a Passive movement i Relaxed passive movements. ii Mobilisation techniques - spinal and peripheral iii Manipulation - spinal and peripheral without anaesthetic. iv Soft tissue stretching. v Traction - spinal and peripheral. b Active movements i Facilitation - aa muscle contraction by the use of c old and sensory stimulation, both epicrictic and proprioceptive followed by activation; bb facilitation of basic and selective movement patterns and reflex mechanisms, including automatic righting, balance and equilibrium reactions in the developmental sequence; cc inhibition of abnormal sensory input, muscle tome, reflex mechanisms or associated reactions. ii Assisted exercises by means of manual, mechanical and hydrotherapy techniques. iii Free exercises - exercise and activities (both subjective and objective) to obtain relaxation, increase joint range, reeducate muschel function, increase muscle power and endurance, correct posture and re-education postural and gait mechanisms. iv Resisted exercises - aa by manual, mechanical and hydrotherapy techniques; bb by power and endurance programmes. v Re-education of functional activities - aa re-education of an rehabilitation in functional activities such as basic movement patterns and gait (both assisted and unassisted); bb Transference, wheelchair activities and other motor activities required for daily living and sport. vi The use of gymnasia, gymnastic therapeutic apparatus, specially constructed children's apparatus, toys and adapted training circuits. vii Supporting activities - these including swimming, riding and wheelchair sports. viii Group activities - these include activities such as ward classes, outpatient classes; pre-natal and post-natal classes, remedial games. ix Breathing exercises - breathing exercises, postural drainage, mobilising exercise for the thorax, inhalation therapy (including the use of intermittent positive pressure, suction and respiratory function tests). x Splints, supports and prostheses - aa training in the use of splints, supports and prostheses for motor activities, including isolated contraction for the activation of powered splints; bb the adaptation of all these methods for all age groups, including infants, children, adolescents and the aged. 4 The use of various massage techniques, including transverse frictions and connective tissue massage. 5 The giving of electrotherapy, including - a high frequency currents; b low frequency currents; c ultrasound; d radiation (excluding X-rays and cosmic Rays). 6 The application of heat and cold. 7 The therapeutic use of water (hydrotherapy). 8 Mechanical aids: a The making and application of splints and supports. b The application of braces, prostheses and other therapeutic and supportive devices, including the selection of wheelchairs. For any further information and/or clarification, please contact the Allied Health Profession's Council of Namibia. Whilst every care is taken to ensure the accuracy of this schedule NAMAF does not accept responsibility for any omission, loss, damage or the consequences thereof. SCHEDULE General rules governing the scale of benefits 001 Unless timely steps (i.e. 24 hours prior to the appointment) are taken to cancel an appointment the relevant fee may be charged, but shall not be payable by medical aid funds. Each case shall, however, be considered on merit and, if circumstances warrant, no fee shall be charged. Modifier 0001 to be quoted

3 002 In exceptional cases where the fee is disproportionately low in relation to the actual services rendered by the practitioner, the practitioner shall provide motivation for a higher fee and such higher fee as may be agreed upon between the practitioner and the fund may be charged. 003 Where a practitioner uses equipment which is not owned by that practitioner, a reduction of 15% of the relevant rate will be applicable. Modifier 0003 must be quoted when this rule is applied 004 In the case of prolonged or costly treatment, the practitioner should first ascertain from the fund concerned whether it will accept financial responsibility in respect of such treatment, since the member may be subject to maximum annual benefits. 005 After a series of 20 treatments in respect of one patient for the same condition, the practitioner concerned shall report to the fund as soon as possible if further treatment is necessary. Payment for treatments in excess of the stipulated number may be granted by the fund after receipt of a letter from the practitioner concerned, motivating the need for such treatment 006 Emergency treatment shall mean a bona-fide, justifiable emergency physiotherapy procedure performed at any hour, which requires the practitioner to travel to the patient or place of treatment. The fee for all visits under this rule shall be the total fee plus 50% and must be motivated. Modifier 0006 must be quoted after the appropriate code number(s) to indicate that this rule is applicable. 007 Practitioners are reminded that a lower fee than that appearing in the Namibian Benchmark Tariffs shall be charged if the customary fee in the area is less than that charged. Reduced fees shall also be charged where the practitioner would have reduced his/her fee in private practice in particular cases. Prolonged treatment or exceptional cases should also receive special consideration in accordance with the usual medical practice 008 The fee in respect of more than one procedure (excluding evaluation and visiting items 407, 501, 502, 701, 702, 703, 704, 705, 801, and 903) performed at the same consultation or visit, shall be the fee for the major procedure plus half the fee in respect of each additional procedure, but under no circumstances may fees be charged for more than three procedures carried out in the treatment of any one condition. Modifier 0008 must then be quoted after the appropriate code numbers for the additional code numbers for the additional procedures to indicate that this rule is applicable. 009 When more than one condition requires treatment and each of these conditions necessitates an individual treatment, they shall be charged as individual treatments. Full details of the nature of the treatments must be stated. Modifier 0009 must then be quoted after the appropriate code number to indicate that this rule is applicable 010 When the treatment times of two completely separate and different conditions overlap, the fee shall be the full fee for the one condition, and 50% of the fee for the other condition. Modifier 0010 must then be quoted after the appropriate code number to indicate that this rule is applicable. 011 Every physiotherapist must acquaint himself with the provisions of the Medical Aid Funds Act, (Act No. 23 of 1995) in connection with the rendering of accounts. Every account shall contain the following particulars: The name and practice code number of the referring practitioner (where applicable). The name of the member. The name of the patient. The name of the medical aid fund. The membership number of the member. The nature of the treatment. The date on which the service was rendered. The code number of the procedure used in the Namibian Benchmark Tariff. 012 In calculating the prices in this schedule, the following rounding method is used: Values N$ 20 and below rounded to the nearest cent, N$ 20+ rounded to the nearest 10 cent. Modifier values are rounded to the nearest cent. When new item prices are calculated, e.g. when applying a modifier, the same rounding scheme should be followed. 013 Where the physiotherapist performs treatment away from the treatment rooms, travelling costs being more than 16 kilometres in total) to be charged according to the AA-rate. Modifier 0013 must be quoted after the appropriate code numbers to show that this rule is applicable. Please note that although only some medical aid funds accept responsibility for the payment of transport expenses, others do so in exceptional cases only. 014 Physiotherapy services rendered in a nursing home or hospital. Modifier 0014 must be quoted after each code. 016 It is recommended that, when such benefits are granted, drugs, consumables and disposable items used during a procedure or issued to a patient on discharge will only be reimbursed by a medical aid fund if the correct NAPPI code is supplied on the account. Modifiers

4 0001 Unkept appointment % of the relevant rate to be deducted where equipment used is not owned by the practitioner 0006 Add 50% of the total fee for the treatment 0008 Only 50% of the fee for these additional procedures may be charged 0009 The full fee for the additional condition may be charged 0010 Only 50% of the fee for the second condition may be charged 0013 Travelling costs (being more than 16 kilometres in total) according to AA-rate. Please note that although only some medical aid funds accept responsibility for the payment of transport expenses, others do so in exceptional cases only Physiotherapy services rendered to an in-patient in a nursing home or hospital. NOTE: Monetary value of ten units = N$ VAT Inclusive. Item Description Units N$ 1 RADIATION THERAPY / MOIST HEAT / CRYOTHERAPY 001 Infra-red, Radiant heat, Wax therapy Hot packs 005 Ultraviolet light Laser beam Cryotherapy 2 LOW FREQUENCY CURRENTS 103 Galvanism, Diodynamic current, Tens. 105 Muscle and nerve stimulating currents Interferential Therapy. 3 HIGH FREQUENCY CURRENTS 201 Shortwave diathermy. 203 Ultrasound Microwave. 4 PHYSICAL MODALITIES 300 Vibration Percussion Massage 303 Myofacial release/soft tissue mobilisation, one or more body parts 310 Neural tissue mobilisation 314 Lymph drainage 304 Acupuncture 305 Re-education of movement/ Exercises (excluding ante- and post-natal exercises) 307 Pre- and post-operative exercises and/or breathing exercises 308 Group exercises (excluding ante- and post-natal exercises - maximum of 10 in a group)

5 Item Description Units N$ 309 Isokinetic treatment. 313 Ante and post natal exercises/counselling 315 Postural drainage Traction. 318 Upper respiratory nebulisation or lavage 319 Nebulisation Intermittent positive pressure ventilation Suction: Level 1 (including sputum specimen taken by suction) 325 Suction: Level 2 (Suction with involvement of lavage as a treatment in a special unit situation or in the respiratory compromised patient) 327 Bagging (used on the intubated unconscious patient or in the severely respiratory distressed patient). 328 Dry needling 5 MANIPULATION/MOBILISATION OF JOINTS OR IMMOBILISATION 401 Spinal Pre meditated manipulation 405 All other joints. 407 Immobilisation (excluding materials). Rule 008 does not apply. 6 REHABILITATION 501 Rehabilitation where the pathology requires the undivided attention of the physiotherapist. Rule 008 does not apply. 502 Hydrotherapy where the pathology requires the undivided attention of the physiotherapist. Rule 008 does not apply. 503 Rehabilitation for Central Nervous System disorders - condition to be clearly stated and fully documented (No other treatment modality may be charged in conjunction with this) 504 EMG Biofeedback treatment 505 Group rehabilitation. Treatment of a patient with disabling pathology in an appropriate facility requiring specific equipment and supervision, without individual attention for the whole treatment session, in accredited venue only and no charge may be levied by facility 506 Stress management 507 Respiratory Re-education and Training Hourly rehabilitation facility fee 7 EVALUATION 701 Evaluation/counselling at the first visit only (to be fully documented) 702 Complex evaluation/counselling at the first visit only (to be fully documented) One complete re-assessment of a patient's condition during the course of treatment, and/or counselling of the patient or his family 704 Lung function: Peak flow (once per treatment) Computerised/Electronic test for lung pathology 707 Physical Performance test. Must be fully documented.

6 Item Description Units N$ 801 Electrical test for diagnostic purposes (including IT curve and Isokinetic tests) for a specific medical condition Effort test - multistage treadmill VISITING CODES 901 Treatment at a nursing home: Relevant fee plus (to be charged only once per day and not with every hospital visit 903 Domicilliary treatments: Relevant fee plus. 10 OTHER 117 Appointment not kept (medical aid funds will not necessarily grant benefits in respect of this item, it will fall into the "By arrangement with the fund" or "Patient own account" category). 937 Bird or equivalent freestanding nebuliser excluding oxygen at hospital per day. 938 Bird or equivalent freestanding nebuliser excluding oxygen domicilliary per day. 939 Cost of material: Single items below N$ plus VAT may be charged for at cost price plus 20% 940 Cost of appliances: Single items below N$ plus VAT may be charged for at cost price plus 20%