Elective Surgery. Operational Guidelines. Effective 1 July This is a living document and will be updated as required

Transcription

1 Elective Surgery Operational Guidelines Effective 1 July 2018 This is a living document and will be updated as required (last updated 2 nd August 2018)

2 ACC contact details Invoicing Team The Elective Surgery Invoicing Team can assist with queries relating to provider numbers, ARTP updates and general enquiries via . Claims Contact Centre Provider Registration For general enquiries, the ACC Claims Helpline will answer your call and refer you for further assistance if required. Phone: Phone: Fax: ebusiness Phone: , option 1 Health Procurement providerhelp@acc.co.nz ebusinessinfo@acc.co.nz If you have a question about your contract or need to update your details, please contact the ACC Health Procurement team: health.procurement@acc.co.nz Engagement and Performance Managers (EPMs) Website EPMs can help you to provide the services outlined in your contract. Details of the EPM in your region can be found on the For more information about ACC, please visit: June 2018

3 Contents 1. Introduction Who can hold this contract? What does the Elective Surgery contract cover Seeking prior approval for surgery from ACC Transfer of Lead Supplier Determining ARTP priority Types of procedures New and revised Elective Surgery codes Botox Injections... 7 Hand and Wrist... 7 Foot and Ankle... 8 Ophthamology... 8 Otolaryngologist (Ear, Nose and Throat) D Imaging... 9 Imaging... 9 Orthotics Outpatient Post Discharge / Post Procedure Care Applying for Red List Status Invoicing Requests and invoices for multiple procedure ESR18 Follow up visits set fee per visit Elective Surgery Budget Service Monitoring Using new technology for ACC surgery Contracted and Regulation Surgery FAQ s Elective Surgery Agreement Appendix Wrist and Hand... 1 Appendix Ankle and Foot Appendix Ophthalmology Appendix Otolaryngologist (Ear Nose and Throat) Appendix D Imaging Appendix Imaging June 2018

4 1. Introduction The following information is designed to help Suppliers holding the ACC Elective Surgery contract to interpret the contract. This is a living document and updated versions will be made available on The Elective Surgery contract is used to fund surgical treatment undertaken by medical specialists in surgical theatres. Important Note If there are any inconsistencies between this document and the contract, the contract takes precedence. This document refers to the 2018/2019 Elective Surgery Contract Variation, which takes effect on 1 July Any links from this document to that Schedule reflect that effective date. 2. Who can hold this contract? The Elective Surgery contract is held by Suppliers who undertake surgical treatment at a facility that: holds current certification with the Ministry of Health under the Health and Disability Services (Safety) Act 2001; and/or holds current accreditation under the NZS 8164:2005 Standard for Day-stay Surgery and Procedures. Please refer to Clause 12 within the Elective Surgery Service Schedule for further details around the Service Specific Requirements for the Elective Surgery contract. The Suppliers may only utilise the services of Specialist Medical Practitioners who are Named Providers under their contract. A Named Provider is either: a Medical Practitioner including an appropriate limited scope registration with the Medical Council of New Zealand or who holds or is deemed to hold vocational registration that is relevant, or an oral maxillofacial surgeon vocationally registered with the Dental Council of New Zealand. August 2018 Page 1

5 3. What does the Elective Surgery contract cover The following services are covered under the Elective Surgery contract: Surgical procedure, inpatient stay and Specialist follow-up prior to discharge. Post-discharge care by a Specialist for a period of six weeks, including the clinically necessary replacement of dressings or casts. Radiology during inpatient stay, but not after discharge. Inpatient physiotherapy. Equipment for up to six weeks after discharge. This includes manufactured items likely to help a client restore their independence and remain safe in daily living. Examples include shower stools, crutches, walking frames, wheelchairs. Orthotics for up to six weeks post-discharge. This covers the fitting and fabrication of orthoses, and related technical aids used to support or correct the function of the trunk, and upper and lower extremities. Examples include splints, shoulder braces. Surgical Implants and implant specific equipment (as defined within Appendix Two of the contract). More detailed information of what ACC considers as inclusions and exclusions for implant costs may be provided in future. In the meantime, if you have any surgical implants and implant specific equipment queries please electivesurgeryinvoices@acc.co.nz rather than the Claims Contact Centre. Note: ACC pays for implants separately from the cost of treatment, paying the supply cost to the Supplier. The Supplier gives proof of cost to the Treatment Assessment Centre (TAC) in the form of an invoice or similar evidence. Note: Some of these services require prior approval from ACC. The following services are not covered in the Elective Surgery contract: Prosthetics. These are provided as aids and appliances. Outpatient physiotherapy and outpatient allied health follow-up after discharge. These are covered by the Cost of Treatment Regulations or appropriate contracts (e.g. Physiotherapy Service contract). Diagnostic imaging services required after the date of discharge. These are covered by the High-Tech Imaging (HTI) contract, and the Costs of Treatment Regulations. Home help, attendant care (home help / personal care) and childcare. Transport and accommodation costs that are additional to the treatment for a Client or an escort. Orthotics or long-term equipment for independence required beyond six weeks postdischarge. Note: some of these services may be provided under a separate ACC contract August 2018 Page 2

6 4. Seeking prior approval for surgery from ACC Written approval is required from ACC before any Elective Surgery and/or certain other procedures is accepted as funded by ACC. The Surgical Assessment Report and Treatment Plan (ARTP) is used to request approval of surgical treatment. Named Providers are required to submit an ARTP, via the Elective Surgery Supplier, for all surgery requests. The ARTP should be submitted within seven working days of assessing the Client. The Elective Surgery Supplier is responsible for ensuring the ARTP meets ACC requirements for submission. The Elective Surgery Supplier should send the ARTP to the Treatment Assessment Centre (TAC) via The Surgical ARTP online is the only version of the ARTP that will be accepted. The ARTP should provide ACC with the information needed to make a decision on the surgery request. If the information cannot be understood or requires clarification, ACC will contact the Named Provider. The ARTP will identify the type of procedure being requested. If the surgery is for Non-core procedures (see section 6 of this document for further information about Non-core), an accurate estimation of costs including implants must also be provided. This should be done by using the ACC self-calculating Non-core pricing sheet. For more information refer to clause of the ACC Elective Surgery Contract. The ARTP should also adequately identify the reasonable clinical prognosis for the Client, including return to independence and/or work, and any reasonably anticipated follow-up care. The TAC will assess the surgery request and advise the Supplier and the Client of ACC s decision. The Elective Surgery Supplier will be notified of the decision via and the Client will be notified by a letter sent via post. If the surgery request is declined, TAC will also advise the Client by phone. Once the proposed procedures are approved, the Supplier is responsible for arranging the earliest possible mutually appropriate date for treatment with the Client. 5. Transfer of Lead Supplier The contract now states the expectation that, where a client agrees to be transferred from one lead supplier to another, the receiving lead supplier will make reasonable demands of the sending supplier concerning medical notes and so on. Where such transfers happen frequently between two suppliers, we recommend that standard protocols be agreed between them, in order that neither party and especially ACC s client is inconvenienced. August 2018 Page 3

7 6. Determining ARTP priority The ARTP priority (that is, the urgency with which TAC should access the ARTP compared with others) should be clearly stated on the ARTP. From 1 May 2017, ACC has utilised a two-tier system to classify the priority of an ARTP. The classifications are either High or Routine. High priority applies if the client meets any one of the following criteria at the time of the surgical consultation: a) The Client s current condition is likely to deteriorate rapidly if the proposed treatment is not carried out within 30 days; OR b) The Client is at risk of losing their job because they are unable to continue in paid employment while waiting on the requested treatment and the proposed treatment is likely to reverse/improve the relevant loss of function; OR c) The Client was employed at the time of the accident and is receiving weekly compensation from ACC; OR d) The Client will require paid assistance (home help or attendant care) to assist with activities of daily living if the proposed treatment is not carried out within 30 days. If the client does not meet any of these criteria, the ARTP should be classified as Routine. When completing the ARTP please ensure that priority codes are indicated as below (noting that there is no order of importance) H1 deteriorating condition H2 home help required H3 receiving weekly compensation H4 risk of losing employment Meeting priority timeframes Surgery approved through a high priority ARTP is expected to be undertaken within one month of the surgery being approved. If a Supplier is unable to meet this requirement for high priority surgery ACC needs to be notified immediately. ACC may, at its sole discretion, either endeavour to agree with the Supplier and the Client an extension of the timeframe, or work with other Suppliers to make alternative arrangements for the provision of the surgery. ACC provides feedback to Suppliers regarding performance against the one month requirement. August 2018 Page 4

8 Changing a Client s priority If a Named Provider or Supplier becomes aware of change in the Client s condition or circumstances that warrant a change of surgery priority classification, they should contact ACC to discuss this. ACC may request a change to the Client s priority classification if the Client s circumstances have changed and they then meet any one of the above criteria for High priority (or no longer meet any of the criteria and their surgery can be prioritised as Routine ). TAC will contact the Supplier in these circumstances. 7. Types of procedures The Elective Surgery contract covers Core and Non-core procedures. A core procedure is a package of care surrounding which includes a particular surgical intervention. A non-core procedure is a package of care surrounding an unusual surgical intervention or unusual condition pertaining to the client, and will be priced and approved on a case by case basis, using the non-core codes described on the non-core price calculation spreadsheet. This spreadsheet can be accessed here. Red List procedures are those which have been assessed by the relevant professional body (most commonly a sub-committee or Society associated with the New Zealand Orthopaedic Association) as requiring a specially trained surgeon. The NZOA also assesses the surgeons who seek to perform such procedures, and advises ACC that such a surgeon should be red listapproved. This process is managed by the relevant professional body, and applications should be made there rather than to ACC. Please note that until confirmation of approval has been issued in writing from ACC on the advice of the professional body, providers can not undertake any of the Red List procedures for ACC. See Paragraph 10, below. Type of Procedure Core (Non-Red List Core) Description Core procedures are listed in the Elective Surgery Service Schedule under Service Items and Prices Part A, Clause 5. All contracted Specialists who are named under an Elective Surgery contract can request Core procedures that are not classified as Red List procedures as required. Suppliers can also access associated items such as ward stay or (under specific approved circumstances) specialist inward follow up visits. August 2018 Page 5

9 Non-core Non-core procedures are not included within the list of Service Items and Prices (part A, Clause 5 of the Elective Surgery Service Schedule). Non-core procedures are usually either: a less common treatment procedure, or a combination of a Core treatment procedure and a procedure that is not listed or an additional service item that is required due to the Client s condition (including co-morbidities). Further information around multiple procedure requests is outlined under Section 9 below. Non-core procedures are not: Core procedures that the provider has not agreed to a contracted price for; and/or Core procedures undertaken by a non-contracted Provider. This would be a Cost of Treatment Regulations (Regulations) procedure. Red List Core All contracted Specialists who are named under an Elective Surgery contract can request Non-core procedures as required. Some of the Core procedures are classified as being Red List procedures. Red List procedures are relatively complex, high cost and low volume procedures (see above). Suppliers can also access associated items such as ward stay or (under specific approved circumstances) specialist inward follow up visits. 8. New and revised Elective Surgery codes. The following codes have been revised for the 2018 /2019 contract variation. This includes descriptions and clinical considerations. The codes are attached in Appendix 1-6. August 2018 Page 6

10 Botox Injections Codes have been developed for botox injections for spasms or contractures. These codes can be used for any body site. Any of these codes must be included on the ARTP for prior approval. Generic codes will be developed at some stage. AFT300 AFT301 Botox for release of spasm/contractures 1 body site. May be used as an equivalent for other body sites. Does not include costs for botox ampoules. These are billed separately using the addon block AFTABOTOX (see below) Botox for release of spasm/contractures 2 body sites. May be used as an equivalent for other body sites. Does not include costs for botox ampoules. These are billed separately using the add-on block AFTABOTOX (see below) AFT302 AFT303 Botox for release of spasm/contractures 3 body sites. May be used as an equivalent for other body sites. Does not include costs for botox ampoules. These are billed separately using the add-on block AFTABOTOX (see below) Botox for release of spasm/contractures 44 body sites. May be used as an equivalent for other body sites. Does not include costs for botox ampoules. These are billed separately using the add-on block AFTABOTOX (see below) AFTABOTX Orthopaedic botox. For costs of botox ampoules used with the codes AFT300 - AFT303 Hand and Wrist Some non-core codes now have core codes and are also red list procedures. Please see guidance above regarding how to become a Red List named provider if you will be undertaking these procedures. There are 2 add on codes for Hand and Wrist. These codes are for minor and major bone grafts and can only be used in conjunction with the Wrist and Hand / Ankle and Foot codes. These codes must be included on the ARTP for prior approval. ORAMINB ORAMAJB "Minor bone graft (add on) for use with procedure codes that don't already include bone graft For bone harvested from a site other than the operation site or the iliac crest." "Major bone graft (add on) for use with procedure codes that don't already include bone graft For bone harvested from the iliac crest. " August 2018 Page 7

11 WAH147 and WAH150 The pricing of these codes did not reflect the additional time required if only a partial wrist fusion procedure is undertaken. ACC will review this in due course. In the meantime Providers can claim additional theatre time using code ESR01. We expect that this will be around 30 minutes. This additional code should be included on the ARTP. Click here to got to Appendix 1 Foot and Ankle Some non-core codes now have core codes and are also red list procedures. Please see guidance above regarding how to become a Red List named provider if you will be undertaking these procedures. There are 3 add on codes for Foot and Ankle. Two codes are for minor and major bone grafts. These codes can only be used in conjunction with the Wrist and Hand / Ankle and Foot codes ORAMINB ORAMAJB Minor bone graft (add on) for use with procedure codes that don't already include bone graft For bone harvested from a site other than the operation site or the iliac crest. Major bone graft (add on) for use with procedure codes that don't already include bone graft For bone harvested from the iliac crest. A further code is available for orthopaedic botox and can be used in conjunction with codes AFT300 AFT303 as described under the section Botox Injections above. Click here to go to Appendix 2 Ophthamology The ophthalmology codes have been revised recently and are attached in appendix 3. Two codes have been developed as add ons. OPTAFRAG OPTAEYEB Fragmatome Use. Add on to be used in conjunction with OPT101-OPT133. National Eye Bank fee. Add on to be used in conjunction with OPT106 Click here to go to Appendix 3. August 2018 Page 8

12 Otolaryngologist (Ear, Nose and Throat) The ENT codes have been revised and are attached in Appendix 4. One add on code has been developed to be used when a turbinoplasty is performed in conjunction with OTY103 OTY109. OTYATURB Endoscopic Powered Inferior Turbinoplasties. Add on to be used in conjunction with OTY103 - OTY109. Click here to go to Appendix 4. 3D Imaging The growth of 3D imaging for use in theatres has seen the development of new codes to support the use of this in line with surgical procedures. From 1 July 2018, 3D Imaging will be funded for a specified list of core procedure codes. This list can be found together with the new core codes in Appendix 5. 3D Imaging can also be considered for use in non-core procedures but would require prior approval from ACC. Imaging The accelerated use of image intensifiers in theatre has led to the development of codes to support this use. Time in theatre is the total time that the machine is under the control of the radiographer and is equivalent to the number of time blocks that radiographer is required. If the time in theatre exceeds 150 minutes the additional time can be invoiced using a top up of the new codes. An example is if the time in theatre was 225 minutes the provider can bill IMAGE5 in combination with IMAGE3. The non-core code of ESR15 for the use of an image intensifier has been removed. You should now use codes IMAGE 1 5 as applicable. See Appendix 6 for the new codes. Orthotics The hire of knee scooters does not require prior approval. They can be billed with the core code with evidence of actual and reasonable cost. Please use EST11 as an add on code when completing the ARTP. August 2018 Page 9

13 9. Outpatient Post Discharge / Post Procedure Care Post discharge / post procedure care begins following discharge from the Treatment Facility and ends six weeks after discharge. Post discharge care includes the replacement and/or removal of casts and dressings. Section 5.4 of the Service Schedule sets out what the post discharge/post procedure care includes. If further specialist care is needed at the end of six weeks this is provided under the Clinical Services Contract or under appropriate Regulations. 10. Applying for Red List Status Application by orthopaedic providers should be made to the New Zealand Orthopaedic Association (NZOA) see clause 5.6.1(g) of Service Schedule. In future, if Red List procedures are identified in other scopes of practice, the relevant professional body will perform the role described for NZOA here. Application to be a named Red List provider should be done directly through NZOA.NZOA will advise ACC and the applicant of the outcome. Due to the required external evaluation from the relevant sub-speciality group the decision-making process can take time. If you have any queries about the application, you should contact NZOA. Once the decision is made ACC will advise the provider that they have been listed on the Red List. It is important to note that Named Providers cannot perform Red List procedures until they receive confirmation of Red List approval from ACC. 11. Invoicing Invoices should be submitted to the Treatment Assessment Centre (TAC) in accordance with Clause of the Service Schedule. All invoices must be submitted to ACC within 12 months of the treatment provided or they will not be paid. Core nor Non-core procedure prices do not include the cost of surgical implants. The Supplier invoices ACC separately for implants and ACC pays the Supplier s actual cost. The supplier is expected to charge ACC the best price the supplier has been able to achieve from the implant vendor, and to make their best efforts to obtain the lowest price possible. August 2018 Page 10

14 Requests and invoices for multiple procedure Suppliers are able to request a combination of Core and Non-core procedures, or request two or more different types of Core procedure to be performed at the same time. If Treatment for a Claim involves two Core procedures from the Service Schedule that will be carried out during the same theatre session. Treatment for a Claim involves three or more Core procedures from the Service Schedule that will be carried out during the same theatre session. The procedure is expected to involve a combination of core and non-core elements or, due to unforeseen circumstances, a combination of core and non-core elements was required at the time of treatment provision. Then Suppliers should submit one ARTP detailing both Core procedures. For invoicing, the total price will be: The price of the most expensive of the procedures plus; 40% of the price of the second procedure. Suppliers should submit a request for a Non-core procedure. The price for the surgery will be determined in accordance with the process set out in clause of the contract. Where the main component of a procedure is equivalent to a Core procedure but additional service items are required, the Supplier must apply for the approval of the procedure, or where the additional service items were unplanned invoice the procedure, as a Core Procedure with the additional service items listed as Non-core units (ESR service codes), and submit the clinical information to support the additional units. Additional services may include but are not limited to additional ward stay, High Dependency Unit care and 2 nd Surgeon Consultant where deemed clinically appropriate. If the Supplier applies for a procedure as Non-core, where the main component of a procedure is equivalent to a Core procedure but additional service items are expected to be required, the Supplier must provide clinical information with the invoicing to support costs. ACC may decline an application for approval as a Non-core procedure and approve the procedure as a Core procedure with additional service items. August 2018 Page 11

15 12. ESR18 Follow up visits set fee per visit For follow up Specialist consultations only during the 6-week post discharge period. This code is not for surgeon follow-up visits in ward prior to discharge. Exception: Where the surgeon has prior approval on a case-by-case basis for in-hospital consultations for complex surgical case, such as (but not limited to) neurosurgery, where such consultations would be considered a clinically necessary episode given the nature of the surgery and the timeframe to discharge. In such instance, there must be an invoice for the follow up with the date of the follow-up, clinical notes (combined across all ward consultations rather than for each visit, - ward notes or a footnote in the patient s progress notes would not be sufficient) and original purchase order number Reasoning: Where the surgeon has identified that the client is considered Highly Complex and will require additional post-operative ward consultations over and above the usual expected and funded under general ward stay provisions, this may be considered for funding under ESR18. The need for extra consultations is to be clearly identified on the ARTP with the supporting clinical rationale. The surgeon will need to provide separate clinical consultation notes (combined across all ward consultations rather than for each visit) at discharge in the same manner as the operation records (a copy of the Ward Notes or a footnote in the patient s progress notes would not be sufficient). These consultation notes are to be submitted along with the invoice to support the costs. Suppliers should note that this provision is a trial until 30 June Elective Surgery Budget Each year, ACC allocates a set budget to each Supplier. Suppliers will be notified of the budget when their contract is issued. Budget phasing information Once the Supplier is notified of their Elective Surgery budget for the forthcoming year, they are required to provide ACC with the Budget Phasing information. This is a monthly projection of the Supplier s spend (excluding Implants and GST). Each Supplier is required to provide ACC with this information under Clause of the Services Schedule. The required date for the 2018/19 Variation is 30 June Budget Management The contract now makes explicit the provision that ACC may authorise a Supplier to continue to provide service beyond their contracted price. If a Supplier is experiencing any issues managing their budget allocation, they should contact their Engagement and Performance Manager. August 2018 Page 12

16 14. Service Monitoring ACC introduced new performance measures to the Elective Surgery contract effective 1 May Under Clause 15 of the Service Schedule, the following measures are monitored: Total volume 1. Volume of ACC surgeries performed by Supplier 2. Measure of surgeries performed by body site 3. Access to elective surgery by clinical priority Measure (a) 75% of High priority surgery is provided within 1 month of the date of ACC s decision to approve surgery; (b) 80% of Routine priority surgery is provided within 6 months of the date of ACC s decision to approve surgery. (a) Average days by facility and surgeon for High priority surgery to be undertaken post approval; (b) Average days by facility and surgeon for Routine priority surgery to be undertaken post approval. % of high-priority clients receiving treatment within target timeframes The performance measures will be monitored by ACC. Suppliers are not required to submit data on these measures to ACC. Feedback on the performance measures will be provided to Suppliers through their Engagement and Performance Manager. It is anticipated that the performance measures will evolve over time to reflect collective priorities. The quality indicators below (numbers 1 5) should be reported as follows: If the Supplier is a member of the New Zealand Private Surgical Hospitals Association, the supplier may choose to meet its Clause 15 obligations by participating in the ACC Indicators Report survey undertaken by the NZPSHA. The details of this are available from the Association If the Supplier is not a member of NZPSHA they must report in line with the table below DHBs are not required to undertake this reporting as they are required to report to the Ministry of Health. Patient reported experience outcomes measures should be forwarded to your Engagement and Planning Manager by the 20 th July 2018, and on the same date in subsequent years. August 2018 Page 13

17 No. Quality Indicator Frequency When 1 Unplanned or unexpected returns to the operating room during same patient admission. 2 Cancellation of elective surgery by the hospital during admission. 3 Unplanned or unexpected transfers to a higher level of care or for additional diagnosis and treatment 4. Day Stay surgery turns into unplanned overnight stays 6 monthly 20 th July monthly 6 monthly 6 monthly 22 January Perioperative deaths before discharge 6 monthly 6 Patient reported experience measure Annually 20 th July Using new technology for ACC surgery The use of new technologies is not automatically approved and requires review of scientific evidence by the Clinical Service Directorate (CSD) Senior Medical Advisors before funding of new technologies is considered. If the use of a new technology is proposed as part of a surgery, please ensure this is highlighted clearly in the ARTP and the Specialist provides an explanation for the use of the new technology as well as rationale how this will support the Client to achieve a better health outcome. An indication of the potential costs is also required. 16. Contracted and Regulation Surgery The following funding categories can be used for elective surgery: Contracted surgery This is the funding route that can be used by Suppliers who hold a current Elective Surgery Contract. This is most common funding route used: o o Contract holders are paid the contracted price contained in the Elective Surgery Service Schedule. This price covers the surgical treatment and the six weeks post-discharge from hospital care. Implants are not included in the contracted price. ACC will pay the Supplier s cost price for implants used and these should be invoiced separately, at the lowest price the supplier can obtain. August 2018 Page 14

18 o The Supplier cannot charge the Client with any additional co-payment 1 for the services. Regulation surgery (noncontracted surgery) This is the funding route that can be used for non-dhb Suppliers who do not hold a current Elective Surgery contract. ACC is liable to pay or contribute to the cost of surgery under regulation 18 of the Accident Compensation (Liability to Pay or Contribute to Cost of Treatment) Regulations 2003 ( non-contracted surgery ). This includes all procedures listed on the Elective Surgery Service Schedule procedure list. o Private hospitals are paid at 60% of the contracted rate. o If the procedure is Non-core, private hospitals are paid 60% of the Non-core price. o All implants are paid at 100%. o Private Hospitals may charge the client a copayment. The Surgeon requesting approval for Regulation surgery is responsible for ensuring that payment is made to the hospital, anaesthetist and others from the ACC contribution amount. The Surgeon can request that a hospital takes on this role. If the hospital agrees, then the hospital is responsible for distributing payments to all parties concerned. Regulation surgery (noncontracted surgery) - DHBs Suppliers should note that ACC is only required to pay for the generally accepted means of treatment for such an injury in New Zealand. (see Schedule 1, clause 2 (2) (b) of the Accident Compensation Act 2001). DHBs may choose to invoice actual costs of treatment under Regulations noting that ACC may decline to pay if the injury is not a covered injury. In addition, Suppliers should note that ACC is only required to pay for the generally accepted means of treatment for such an injury in New Zealand. (see Schedule 1, clause 2 (2) (b) of the Accident Compensation Act 2001). DHBs taking this route are advised to continue to seek 1 A co-payment is any amount paid by the client to cover the remaining costs between ACC s contribution and the total amount charged by a non-contracted provider. August 2018 Page 15

19 ARTP approval, and to invoice using the ES contract code structure, to avoid payment being declined or evidence of actual cost being required. Under ACC s Standard Terms and Conditions a Supplier under the Elective Surgery Contract (except a DHB) may not choose to invoice ACC under Regulations for a procedure covered by the Elective Surgery Contract. It is important that Clients are made aware of the option to have their surgery fully funded through a contracted Supplier. ACC has a requirement to inform the Client that surgery can be performed by a contracted Provider at no cost to the Client, even though this may mean the client receives treatment from an alternative, contracted provider other than the clinician whom they have originally consulted. This information is provided directly to the Client in a decision letter. The Client must sign the letter and return it to ACC to demonstrate their understanding and consideration of all the options available. Failure to complete this process can result in delays to treatment, so Suppliers and Providers are expected to assist clients in this process. A discussion regarding options will need to occur after the approval decision for surgery, when all information is available. This will result in a second consultation regarding surgical options, which can be invoiced using the Clinical Services contract. ACC will also pay for one such consultation under the clinical services contract after a decision not to fund treatment, so that the patient may have funding alternatives explained to them. ACC requires the completed documentation before any payments can be made for the provision of surgery. August 2018 Page 16

20 17. FAQ s Elective Surgery Agreement Q. Can I charge a co-payment? A. No, not for contracted surgery. The price for each service is the amount chargeable and no additional amount may be charged. If the surgery is non-contracted and undertaken in a DHB ACC pays 100% and no copayment can be charged. If the non-contracted surgery is undertaken in a private hospital ACC pays 60% of the contracted price and the client can be charged a copayment. Q. Where do I send the ARTP? A. All ARTPs are sent to the Treatment Assessment Centre - ARTPS4ESU@acc.co.nz Q. The surgical treatment I need to provide is not listed in this contract. What can I do? A. Complete an ARTP for a Non-core procedure and submit to the Treatment Assessment Centre. Q. My patient does not have a case manager and requires further assistance from ACC. Who do I contact? A. Contact the Claims Contact Centre on Q. Does ACC pay for Registered Nurse Surgeon Assistants under Non-core code ESR10 2 nd surgeon assistant? A. No. ESR10 is for funding assistant surgeons who are qualified medical practitioners. Nurse assistant costs are part of the ESR01 and ESR02 code price (Theatre time). Q. I am not sure how to invoice for a procedure completed which is different to what was approved by ACC. What do I do or who do I contact? A. For any elective surgery invoice/coding related queries, please electivesurgeryinvoices@acc.co.nz rather than the Claims Contact Centre. You will need to have available medical notes to justify any unanticipated changed in approved procedure. August 2018 Page 17

21 Appendix 1 Wrist and Hand Current Code Current Description Code 2018/2019 New Description WAH01 ORIF - Phalangeal fracture WAH100 Closed reduction and k-wiring of phalangeal and metacarpal fractures WAH01 ORIF - Phalangeal fracture WAH101 Open Reduction Internal Fixation (ORIF) phalangeal fracture - Simple Includes: - simple shaft fractures - if 2 digits, each attract a separate code - if > 2 digits then this becomes a noncore procedure WAH01 ORIF - Phalangeal fracture WAH102 Open Reduction Internal Fixation (ORIF) phalangeal fracture Complex Includes: - intra-articular fractures, complex comminuted shaft fractures, pilon fractures - if 2 digits, each attract a separate code - if > 2 digits then this becomes a noncore procedure WAH01 ORIF - Phalangeal fracture WAH103 Hemi-hamate reconstruction of pilon fracture WAH02 ORIF - Metacarpal fracture WAH104 Open Reduction Internal Fixation (ORIF) metacarpal Simple Includes: - simple metacarpal shaft fractures - if 2 digits, each attract a separate code - if > 2 digits then this becomes a noncore procedure WAH02 ORIF - Metacarpal fracture WAH105 Open Reduction Internal Fixation (ORIF) metacarpal Complex Includes: - intra-articular fractures and 4th and 5th carpometacarpal fracture dislocation - if 2 digits, each attract a separate code - if > 2 digits then this becomes a noncore procedure August 2018 Page 1

22 Current Code Current Description Code 2018/2019 New Description WAH03 Corrective Osteotomy of Phalanx WAH106 Corrective Osteotomy of phalanx Includes: - internal fixation - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH04 Corrective osteotomy of Metacarpal WAH107 Corrective osteotomy of metacarpal Includes: - internal fixation WAH05 Arthrodesis IP joint WAH108 Arthrodesis Interphalangeal (IP) joint Includes: - internal fixation - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH06 Arthrodesis CMC joint WAH109 Arthrodesis Carpometacarpal (CMC) joint Includes: - internal fixation - bone graft WAH07 Arthrodesis MCP joint WAH110 Arthrodesis Metacarpophalangeal (MCP) joint Includes: - internal fixation - bone graft WAH09 CMC Joint Arthroplasty WAH111 Carpometacarpal (CMC) joint arthroplasty Simple Includes: - trapeziumectomy, debridement of joints, excision of avulsion fragments August 2018 Page 2

23 Current Code Current Description Code 2018/2019 New Description WAH09 CMC Joint Arthroplasty WAH112 Carpometacarpal (CMC) joint arthroplasty Complex Includes: trapeziumectomy plus ligament reconstruction and tendon interposition (LRTI), implant arthroplasty and beak ligament reconstruction WAH10 Replacement - MCP/ IP joint WAH113 Metacarpophalangeal (MCP) joint arthroplasty Simple Includes: - silicone arthroplasty (e.g. Swanson) - if 2 digits, each attract a separate code - if > 2 digits then this becomes a noncore procedure WAH10 Replacement - MCP/ IP joint WAH114 Metacarpophalangeal (MCP) joint arthroplasty Complex Includes: - cemented and uncemented 2 component implant - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH11 Repair Collateral Ligament joint - Wrist WAH115 Repair collateral ligament MCP joint/ IP joint (Metacarpophalangeal joint/interphalangeal joint) Includes: - volar plate repair WAH12 Reconstruction Collateral Ligament - joint WAH116 Reconstruction collateral ligament MCP joint/ IP joint - using tendon graft (Metacarpophalangeal joint/interphalangeal joint) Includes: - volar plate reconstruction with FDS (flexor digitorum superficialis tendon), volar plate advancement WAH13 Simple Amputation Digit WAH117 Simple amputation - Digit - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH14 Ray Amputation Digit WAH118 Ray Amputation - Digit August 2018 Page 3

24 Current Code Current Description Code 2018/2019 New Description WAH20 Tenolysis Flexor Tendon WAH119 Tenolysis flexor tendon Simple Includes: - A1 pulley release, traction tenolysis, flexor tenotomy - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH20 Tenolysis Flexor Tendon WAH120 Red List Tenolysis flexor tendon Complex Includes: - excision of slip of FDS (flexor digitorum superficialis tendon), tenolysis plus arthrolysis of MCPJ/IPJ (Metacarpophalangeal joint/interphalangeal joint) - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH21 Tenolysis Extensor Tendon WAH121 Tenolysis extensor tendon Simple Includes: - release stenosing tenosynovitis (incl. De Quervains), intersection syndrome, extensor tenotomy - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH21 Tenolysis Extensor Tendon WAH122 Tenolysis extensor tendon Complex Includes: - tenolysis plus arthrolysis MCPJ/IPJ (Metacarpophalangeal joint/interphalangeal joint) - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH15 Repair Flexor Tendon in Digit or Palm WAH123 Repair flexor tendon digit or palm - if two tendons, each attract a separate code, - if > 2 then this becomes a non-core procedure August 2018 Page 4

25 Current Code Current Description Code 2018/2019 New Description WAH16 Repair Flexor Tendon Wrist or Forearm WAH124 Repair flexor tendon wrist or forearm proximal to the carpal tunnel - if two tendons, each attract a separate code, - if > 2 then this becomes a non-core procedure WAH17 Extensor Tendon Repair - Hand/Finger WAH125 Repair extensor tendon digit or hand/ wrist or forearm - if two tendons, each attract a separate code, - if > 2 then this becomes a non-core procedure WAH19 Reconstruction Flexor Tendon WAH126 Red List Reconstruction flexor tendon using primary tendon graft Includes: - harvest of tendon graft - if two tendons, each attract a separate code, - if > 2 then this becomes a non-core procedure Excludes: tendon transfer NONCORE Non core procedure WAH127 Red List Reconstruction flexor tendon - 1st Stage tendon reconstruction Includes: - insertion of spacer/rod - if two tendons, each attract a separate code, - if > 2 then this becomes a non-core procedure Excludes: tendon transfer NONCORE Non core procedure WAH 128 Red List Reconstruction flexor tendon - 2nd Stage tendon reconstruction Includes: - harvest of tendon graft - if two tendons, each attract a separate code, - if > 2 then this becomes a non-core procedure Excludes: tendon transfer August 2018 Page 5

26 Current Code Current Description Code 2018/2019 New Description WAH18 Reconstruction Extensor Tendon WAH129 Red List Reconstruction extensor tendon using primary tendon graft Includes: - harvest of tendon graft - if two tendons, each attract a separate code, - if > 2 then this becomes a non-core procedure Excludes: tendon transfer - Should a Staged procedure be required, this would become noncore WAH23 Pulley Reconstruction WAH130 Red List Pulley reconstruction - Includes: required tenolysis, use of local tendon or free tendon graft, extensor retinacular reconstruction i.e. ECU (extensor carpi ulnaris ) stabilization - if two tendons, each attract a separate code, - if > 2 then this becomes a non-core procedure WAH24 Tendon Transfer WAH131 Tendon transfer for tendon rupture - Includes: side to side transfer, end to end transfer, end to side - if two transfers required, each attract a separate code, - if > 2 then this becomes a non-core procedure WAH28 Carpal Tunnel Release WAH132 Carpal tunnel release Simple - open surgery Primary WAH28 Carpal Tunnel Release WAH133 Carpal tunnel release Complex Open surgery Includes Revision Deep exploration, Extensive neurolysis and tenolysis, +/- vein conduit wrap, +/- local fat flap NONCORE Non core procedure WAH134 Red List Carpal tunnel release endoscopic August 2018 Page 6

27 Current Code Current Description Code 2018/2019 New Description WAH29 ORIF Scaphoid Fracture WAH135 Open Reduction Internal Fixation (ORIF) scaphoid or other carpal bone (includes Hook of Hamate) Includes: - open or percutaneous screw fixation WAH31 Reconstruction Carpal Bone WAH136 Scaphoid or other carpal bone reconstruction Simple Includes: - bone graft from distal radius and fixation WAH31 Reconstruction Carpal Bone WAH137 Red List Scaphoid or other carpal bone reconstruction Complex Using structural bone grafting from iliac crest and fixation. Includes: - bone graft from iliac crest and fixation - if a vascularised bone graft is required, this becomes a noncore procedure WAH42 Diagnostic Arthroscopy Wrist WAH138 Red List Wrist arthroscopic surgery Simple Includes: - diagnostic arthroscopy and/or removal of loose bodies, simple debridement of synovitis WAH43 Arthrosc Debridemt/Repair TFC/Repair Carpal Ligamt WAH139 Red List Wrist arthroscopy proceed to open surgery Simple Includes: - diagnostic arthroscopy and/or removal of loose bodies, simple debridement of synovitis NONCORE Non core procedure WAH140 Wrist open surgery Simple Includes: - removal of loose bodies, simple debridement of synovitis WAH43 Arthrosc Debridemt/Repair TFC/Repair Carpal Ligamt WAH141 Red List Wrist arthroscopy - Complex 1 - (Intercarpal ligament injury) Includes: - Percutaneous K wiring of joints for intercarpal ligament injury WAH42 & WAH32 Combination of codes WAH142 Red List Wrist arthroscopy and proceed to open - Complex 1 Includes: - Repair of intercarpal ligament and K-wiring of joints WAH42 & WAH33 Combination of codes WAH143 Red List Wrist arthroscopy and proceed to open Complex 1 Includes: - Reconstruction of intercarpal ligament and K-wiring of joints WAH32 Repair Ligament Injury for Carpal WAH144 Wrist Open Surgery Complex 1 Repair of intercarpal ligament and K-wiring of joints August 2018 Page 7

28 Current Code Current Description Code 2018/2019 New Description WAH33 Instability Reconstruction for Carpal Instability WAH145 Wrist open surgery - Complex 1 - Reconstruction of intercarpal ligament and K-wiring of joints WAH42 & WAH39 Combination of codes WAH146 Wrist arthroscopy and proceed to open - Complex 2 - Arthroscopic and proceed to open Proximal Row Carpectomy (PRC) WAH42 & WAH36 & WAH37 Combination of codes WAH147 Wrist arthroscopy and proceed to open - Complex 2 - Partial wrist fusion and Sauve-Kapandji procedure WAH42 & WAH38 Combination of codes WAH148 Wrist arthroscopy and proceed to open - Complex 2 Total Wrist Fusion WAH39 Wrist -Proximal Row Carpectomy WAH149 Wrist open surgery - Complex 2 - Proximal Row Carpectomy (PRC) WAH36 & WAH37 Combination of codes WAH150 Wrist open surgery - Complex 2 - Partial wrist fusion and Sauve-Kapandji procedure WAH38 Arthrodesis - Wrist with Bone Graft WAH151 Wrist open surgery - Complex 2 - Total wrist fusion WAH43 Arthrosc Debridemt/Repair TFC/Repair Carpal Ligamt WAH152 Wrist arthroscopy - Complex 3 TFCC injury (triangular fibrocartilage complex) Includes: - diagnosis and TFCC (triangular fibrocartilage complex) debridement WAH43 Arthrosc Debridemt/Repair TFC/Repair Carpal Ligamt WAH153 Wrist arthroscopy - Complex 3 Includes: - diagnosis, debridement & repair of TFCC (triangular fibrocartilage complex) tear WAH42 & WAH34 Combination of codes WAH154 Wrist arthroscopy and proceed to open - Complex 3 Includes: - diagnosis, debridement & open repair of TFCC (triangular fibrocartilage complex) tear WAH42 & WAH35 Combination of codes WAH155 Wrist arthroscopy and proceed to open - Complex 3 - Open TFCC (triangular fibrocartilage complex) reconstruction with tendon graft WAH34 Open Triangular Fibro-Cartilage Repair WAH156 Wrist open surgery - Complex 3 - Open TFCC (triangular fibrocartilage complex) repair WAH35 Reconstruction DRUJ for Instability WAH157 Wrist open surgery - Complex 3 - Open TFCC (triangular fibrocartilage complex) reconstruction with tendon graft ELF09 ORIF Fracture Radius or Ulna WAH158 Open Reduction Internal Fixation (ORIF) distal radius Includes: - ORIF radial styloid August 2018 Page 8

29 Current Code Current Description Code 2018/2019 New Description WAH41 Recons/Corrective Ulnar Osteotomy w Internl Fixatn WAH159 Corrective osteotomy distal radius Includes: Internal fixation NONCORE Non core procedure WAH160 Styloidectomy distal radius ELF09 ORIF Fracture Radius or Ulna WAH161 Open Reduction Internal Fixation (ORIF) ulna Includes: - Open Reduction Internal Fixation (ORIF) shaft - distal and styloid WAH41 Recons/Corrective Ulnar Osteotomy w Internl Fixatn WAH162 Corrective osteotomy ulna Includes: - Realignment and shortening - Internal fixation NONCORE Non core procedure WAH163 Styloidectomy ulna WAH44 Release of Scar/Fasciectomy - hand, major WAH45 Release of Scar/Fasciectomy - palm/finger, minor WAH164 WAH165 WAH46 Excision Pisiform WAH166 Excision Pisiform Release of Scar/ Fasciectomy hand - major WAH47 Excision Hook of Hamate WAH167 Excision Hook of Hamate WAH48 Repair Nail Bed WAH168 Repair Nail Bed Release of Scar/ Fasciectomy - palm/ finger - minor WAH49 Reconstruction Nail Bed WAH169 Nailbed (finger) reconstruction Simple Includes: - excision and partial ablation WAH49 Reconstruction Nail Bed WAH170 Nailbed (finger) reconstruction Complex Includes: - nailbed grafting locally or from toe August 2018 Page 9

30 Current Code Current Description Code 2018/2019 New Description WAH08 Arthrolysis/ Synovectomy joint WAH122 Tenolysis extensor tendon Complex Includes: - tenolysis plus arthrolysis MCPJ/IPJ (Metacarpophalangeal joint/interphalangeal joint) - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH22 Tenotomy Hand/Wrist WAH119 Tenolysis flexor tendon Simple Includes: - A1 pulley release, traction tenolysis, flexor tenotomy - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH22 Tenotomy Hand/Wrist WAH121 Tenolysis extensor tendon Simple Includes: - release stenosing tenosynovitis (incl. De Quervains), intersection syndrome, extensor tenotomy - if 2 digits, each attract a separate code - if > 2 digits then this becomes a non-core procedure WAH25 WAH26 Reconstruction for Radial Nerve Palsy Reconstruction for Ulnar Nerve Palsy (Claw hand) NONCORE NONCORE Non core procedure Non core procedure WAH27 Reconstruction Median Nerve Palsy NONCORE Non core procedure WAH30 Revascularisation Carpal Bone NONCORE Non core procedure WAH36 Sauve Kapandji procedure WAH147 Wrist arthroscopy and proceed to open - Complex 2 - Partial wrist fusion and Sauve-Kapandji procedure August 2018 Page 10