GEMS Bemoans Inappropriate ICD-10 Z-Code Usage

GEMS Bemoans Inappropriate ICD-10 Z-Code Usage

Dear Doctor

THE INAPPROPRIATE USE OF Z-CODES IN CLAIMS SUBMITTED TO THE SCHEME

It is almost a year since GEMS’ communication to healthcare practitioners encouraging the use of specific ICD-10 Codes on claims submitted to the Scheme.
The recent GEMS audit done on claims received to date indicates the continued use of Z-Codes on a number of claims that have been processed by the Scheme.

The high utilisation of Z-Codes by some healthcare practitioners was discussed at great length at the meeting held between GEMS and the South African Medical Association (SAMA) in 2015. SAMA reinforced their position in discouraging the use of Z-codes in instances where the healthcare practitioner is aware of the diagnosis. It was mutually agreed that, going forward, the inappropriate use of Z-Codes would be closely monitored, discouraged and kept to an absolute minimum. It was further agreed that comprehensive ICD-10 Codes must be included on all referrals and scripts.

The value of using accurate ICD-10 coding classification for diagnosis codes

Providing the appropriate ICD-10 Code is especially important for claims that qualify as prescribed minimum benefits (PMBs) and for patients who need to access their chronic benefits. In these two instances the inappropriate use of Z-Codes may result in; the depletion of your patients’ savings, claims being short paid, rejected or paid from an incorrect benefit.

Our partnership with SAMA and GEMS to promote coding accuracy

We encourage all healthcare practitioners to submit a valid ICD-10 Code that accurately relates to the condition that the patient has been diagnosed with.

The inappropriate use of Z-Codes also has a significant impact on our ability to effectively;

  1. Structure comprehensive benefit packages
  2. Process claims correctly
  3. Monitor resource utilisation
  4. Track public concerns and assess risks of adverse health events
  5. Measure the quality, safety and efficacy of care

For more information on ICD-10 Codes, please visit the Department of Health website at www.health.gov.za (PATH: Documents/Notices).

To view or validate an ICD-10 Code, visit the GEMS website at www.gems.gov.za(click on Healthcare Providers and then ICD-10 Code/Formulary Check).

Kind regards

GEMS Network Management

 



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