Annexure A
Explanatory Note
The objective of specifying a set of Prescribed Minimum Benefits within these regulations is two-fold:(i)To avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilisation of public hospitals.(ii)To encourage improved efficiency in the allocation of Private and Public health care resources.The Department of Health recognises that there is constant change in medical practice and available medical technology. It is also aware that this form of regulation is new in South Africa. Consequently, the Department shall monitor the impact, effectiveness and appropriateness of the Prescribed Minimum Benefits provisions. A review shall be conducted at least every two years by the Department that will involve the Council for Medical Schemes, stakeholders, Provincial health departments and consumer representatives. In addition, the review will focus specifically on development of protocols for the medical management of HIV/AIDS. These reviews shall provide recommendations for the revision of the Regulations and Annexure A on the basis of:(i)inconsistencies or flaws in the current regulations;(ii)the cost-effectiveness of health technologies or interventions;(iii)consistency with developments in health policy; and(iv)the impact on medical scheme viability and its affordability to Members.Prescribed minimum benefits
Categories (Diagnosis and Treatment Pairs) constituting the Prescribed Minimum Benefits Package under Section 29(1)(o) of the Medical Schemes Act (listed by Organ-System chapter)Brain and nervous system
CODE: 906ADIAGNOSIS: ACUTE GENERALISED PARALYSIS, INCLUDING POLIO AND GUILLAIN-BARRETREATMENT: MEDICAL MANAGEMENT; VENTILATION AND PLASMAPHERESISCODE: 341ADIAGNOSIS: BASAL GANGLIA, EXTRA-PYRAMIDAL DISORDERS; OTHER DYSTONIAS NOSTREATMENT: INITIAL DIAGNOSIS; INITIATION OF MEDICAL MANAGEMENTCODE: 950ADIAGNOSIS: BENIGN AND MALIGNANT BRAIN TUMOURS, TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 49ADIAGNOSIS: COMPOUND/DEPRESSED FRACTURES OF SKULLTREATMENT: CRANIOTOMY/CRANIECTOMYCODE: 213ADIAGNOSIS: DIFFICULTY IN BREATHING, EATING, SWALLOWING, BOWEL, OR BLADDER CONTROL DUE TO NON-PROGRESSIVE NEUROLOGICAL (INCLUDING SPINAL) CONDITION OR INJURYTREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATIONCODE: 83ADIAGNOSIS: ENCEPHALOCELE; CONGENITAL HYDROCEPHALUSTREATMENT: SHUNT; SURGERYCODE: 902ADIAGNOSIS: EPILEPSY (STATUS EPILEPTICUS, INITIAL DIAGNOSIS, CANDIDATE FOR NEUROSURGERY)TREATMENT: MEDICAL MANAGEMENT; VENTILATION; NEUROSURGERYCODE: 211ADIAGNOSIS: INTRASPINAL AND INTRACRANIAL ABSCESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 905ADIAGNOSIS: MENINGITIS - ACUTE AND SUBACUTETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 513ADIAGNOSIS: MYASTHENIA GRAVIS; MUSCULAR DYSTROPHY; NEURO-MYOPATHIES NOSTREATMENT: INITIAL DIAGNOSIS; INITIATION OF MEDICAL MANAGEMENT; THERAPY FOR ACUTE COMPLICATIONS AND EXACERBATIONSCODE: 510ADIAGNOSIS: PERIPHERAL NERVE INJURY WITH OPEN WOUNDTREATMENT: NEUROPLASTYCODE: 940ADIAGNOSIS: REVERSIBLE CNS ABNORMALITIES DUE TO OTHER SYSTEMIC DISEASETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 1ADIAGNOSIS: SEVERE/MODERATE HEAD INJURY: HEMATOMA/EDEMA WITH LOSS OF CONSCIOUSNESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATIONCODE: 84ADIAGNOSIS: SPINA BIFIDATREATMENT: SURGICAL MANAGEMENTCODE: 941ADIAGNOSIS: SPINAL CORD COMPRESSION, ISHAEMIA OR DEGENERATIVE DISEASE NOSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 901ADIAGNOSIS: STROKE - DUE TO HAEMORRHAGE, OR ISCHAEMIATREATMENT: MEDICAL MANAGEMENT; SURGERYCODE: 28ADIAGNOSIS: SUBARACHNOID AND INTRACRANIAL HEMORRHAGE/HEMATOMA; COMPRESSION OF BRAINTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 305ADIAGNOSIS: TETANUSTREATMENT: MEDICAL MANAGEMENT; VENTILATIONCODE: 265ADIAGNOSIS: TRANSIENT CEREBRAL ISCHEMIA; LIFE-THREATENING CEREBROVASCULAR CONDITIONS NOSTREATMENT: EVALUATION; MEDICAL MANAGEMENT; SURGERYCODE: 109ADIAGNOSIS: VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED WITH INJURY TO SPINAL CORDTREATMENT: REPAIR/RECONSTRUCTION; MEDICAL MANAGEMENT; INPATIENT REHABILITATION UP TO 2 MONTHSCODE: 684ADIAGNOSIS: VIRAL MENINGITIS, ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITISTREATMENT: MEDICAL MANAGEMENTEye
CODE: 47BDIAGNOSIS: ACUTE ORBITAL CELLULITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 394BDIAGNOSIS: ANGLE-CLOSURE GLAUCOMATREATMENT: IRIDECTOMY; LASER SURGERY; MEDICAL AND SURGICAL MANAGEMENTCODE: 586BDIAGNOSIS: BELL'S PALSY; EXPOSURE KERATOCONJUNCTIVITISTREATMENT: TARSORRHAPHY; MEDICAL AND SURGICAL MANAGEMENTCODE: 950BDIAGNOSIS: CANCER OF EYE & ORBIT - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 901BDIAGNOSIS: CATARACT; APHAKIATREATMENT: EXTRACTION OF CATARACT; LENS IMPLANTCODE: 911BDIAGNOSIS: CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXATREATMENT: CONJUNCTIVAL FLAP; MEDICAL MANAGEMENTCODE: 405BDIAGNOSIS: GLAUCOMA ASSOCIATED WITH DISORDERS OF THE LENSTREATMENT: SURGICAL MANAGEMENTCODE: 386BDIAGNOSIS: HERPES ZOSTER & HERPES SIMPLEX WITH OPHTHALMIC COMPLICATIONSTREATMENT: MEDICAL MANAGEMENTCODE: 389BDIAGNOSIS: HYPHEMATREATMENT: REMOVAL OF BLOOD CLOT; OBSERVATIONCODE: 485BDIAGNOSIS: INFLAMMATION OF LACRIMAL PASSAGESTREATMENT: INCISION; MEDICAL MANAGEMENTCODE: 909BDIAGNOSIS: OPEN WOUND OF EYEBALL AND OTHER EYE STRUCTURESTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 407BDIAGNOSIS: PRIMARY AND OPEN ANGLE GLAUCOMA WITH FAILED MEDICAL MANAGEMENTTREATMENT: TRABECULECTOMY; OTHER SURGERYCODE:419BDIAGNOSIS: PURULENT ENDOPHTHALMITISTREATMENT: VITRECTOMYCODE: 922BDIAGNOSIS: RETAINED INTRAOCULAR FOREIGN BODYTREATMENT: SURGICAL MANAGEMENTCODE: 904BDIAGNOSIS: RETINAL DETACHMENT, TEAR AND OTHER RETINAL DISORDERSTREATMENT: VITRECTOMY; LASER TREATMENT; OTHER SURGERYCODE: 906BDIAGNOSIS: RETINAL VASCULAR OCCLUSION; CENTRAL RETINAL VEIN OCCLUSIONTREATMENT: LASER SURGERYCODE: 409BDIAGNOSIS: SYMPATHETIC UVEITIS AND DEGENERATIVE DISORDERS AND CONDITIONS OF GLOBE; SIGHT THREATENING THYROID OPTOPATHYTREATMENT: ENUCLEATION; MEDICAL MANAGEMENT; SURGERYEar, nose, mouth and throat
CODE: 33CDIAGNOSIS: ACUTE AND CHRONIC MASTOIDITISTREATMENT: MASTOIDECTOMY; MEDICAL MANAGEMENTCODE: 482CDIAGNOSIS: ACUTE OTITIS MEDIATREATMENT: MEDICAL AND SURGICAL MANAGEMENT, INCLUDING MYRINGOTOMYCODE: 900CDIAGNOSIS: ACUTE UPPER AIRWAY OBSTRUCTION, INCLUDING CROUP, EPIGLOTTITIS AND ACUTE LARYNGOTRACHEITISTREATMENT: MEDICAL MANAGEMENT; INTUBATION; TRACHEOSTOMYCODE: 950CDIAGNOSIS: CANCER OF ORAL CAVITY, PHARYNX, NOSE, EAR, AND LARYNX - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 241CDIAGNOSIS: CANCRUM ORISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 38CDIAGNOSIS: CHOANAL ATRESIATREATMENT: REPAIR OF CHOANAL ATRESIACODE: 133CDIAGNOSIS: CHOLESTEATOMATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 910CDIAGNOSIS: CHRONIC UPPER AIRWAY OBSTRUCTION, RESULTING IN COR PULMONALETREATMENT: SURGICAL AND MEDICAL MANAGEMENTCODE: 901CDIAGNOSIS: CLEFT PALATE AND/OR CLEFT LIP WITHOUT AIRWAY OBSTRUCTIONTREATMENT: REPAIRCODE: 12CDIAGNOSIS: DEEP OPEN WOUND OF NECK, INCLUDING LARYNX; FRACTURE OF LARYNX OR TRACHEA, OPENTREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATIONCODE: 346CDIAGNOSIS: EPISTAXIS - NOT RESPONSIVE TO ANTERIOR PACKINGTREATMENT: CAUTERY / REPAIR / CONTROL HEMORRHAGECODE: 521CDIAGNOSIS: FOREIGN BODY IN EAR & NOSETREATMENT: REMOVAL OF FOREIGN BODY; AND MEDICAL AND SURGICAL MANAGEMENTCODE: 29CDIAGNOSIS: FOREIGN BODY IN PHARYNX, LARYNX, TRACHEA, BRONCHUS & ESOPHAGUSTREATMENT: REMOVAL OF FOREIGN BODYCODE: 339CDIAGNOSIS: FRACTURE OF FACE BONES, ORBIT, JAW; INJURY TO OPTIC AND OTHER CRANIAL NERVESTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 219CDIAGNOSIS: LEUKOPLAKIA OF ORAL MUCOSA, INCLUDING TONGUETREATMENT; INCISION/EXCISION; MEDICAL MANAGEMENTCODE: 132CDIAGNOSIS: LIFE-THREATENING DISEASES OF PHARYNX NOS, INCLUDING RETROPHARYNGEAL ABSCESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 457CDIAGNOSIS: OPEN WOUND OF EAR-DRUMTREATMENT: TYMPANOPLASTY; MEDICAL MANAGEMENTCODE: 240CDIAGNOSIS: PERITONSILLAR ABSCESSTREATMENT: INCISION AND DRAINAGE OF ABSCESS; TONSILLECTOMY; MEDICAL MANAGEMENTCODE: 347CDIAGNOSIS: SIALOADENITIS; ABSCESS / FISTULA OF SALIVARY GLANDSTREATMENT: SURGERYCODE: 543CDIAGNOSIS: STOMATITIS, CELLULITIS AND ABSCESS OF ORAL SOFT TISSUE; VINCENTSANGINATREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENTRespiratory system
CODE: 903DDIAGNOSIS: BACTERIAL, VIRAL, FUNGAL PNEUMONIATREATMENT: MEDICAL MANAGEMENT, VENTILATIONCODE: 158DDIAGNOSIS: # RESPIRATORY FAILURE, REGARDLESS OF CAUSETREATMENT: # MEDICAL MANAGEMENT; OXYGEN; VENTILATIONCODE: 157DDIAGNOSIS: ACUTE ASTHMATIC ATTACK; PNEUMONIA DUE TO RESPIRATORY SYNCYTIAL VIRUS IN PERSONS UNDER AGE 3TREATMENT: MEDICAL MANAGEMENTCODE: 125DDIAGNOSIS: ADULT RESPIRATORY DISTRESS SYNDROME; INHALATION AND ASPIRATION PNEUMONIASTREATMENT: MEDICAL MANAGEMENT; VENTILATIONCODE: 315DDIAGNOSIS: ATELECTASIS (COLLAPSE OF LUNG)TREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATIONCODE: 340DDIAGNOSIS: BENIGN NEOPLASM OF RESPIRATORY AND INTRATHORACIC ORGANSTREATMENT: BIOPSY; LOBECTOMY; MEDICAL MANAGEMENT; RADIATION THERAPYCODE: 950DDIAGNOSIS: CANCER OF LUNG, BRONCHUS, PLEURA, TRACHEA, MEDIASTINUM & OTHER RESPIRATORY ORGANS-TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 170DDIAGNOSIS: EMPYEMA AND ABSCESS OF LUNGTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 934DDIAGNOSIS: FRANK HAEMOPTYISISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 203DDIAGNOSIS: HYPOPLASIA AND DYSPLASIA OF LUNGTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 900DDIAGNOSIS: OPEN FRACTURE OF RIBS AND STERNUM; MULTIPLE RIB FRACTURES; FLAIL CHESTTREATMENT: MEDICAL AND SURGICAL MANAGEMENT, VENTILATIONCODE: 5DDIAGNOSIS: PNEUMOTHORAX AND HAEMOTHORAXTREATMENT: TUBE THORACOSTOMY / THORACOTOMYHeart and vasculature
CODE: 155EDIAGNOSIS: MYOCARDITIS; CARDIOMYOPATHY; TRANSPOSITION OF GREAT VESSELS; HYPOPLASTIC LEFT HEART SYNDROMETREATMENT: MEDICAL AND SURGICAL MANAGEMENT; CARDIAC TRANSPLANTCODE: 108EDIAGNOSIS: PERICARDITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 907EDIAGNOSIS: ACUTE AND SUBACUTE ISCHEMIC HEART DISEASE, INCLUDING MYOCARDIAL INFARCTION AND UNSTABLE ANGINATREATMENT: MEDICAL MANAGEMENT; SURGERY; PERCUTANEOUS PROCEDURESCODE: 284EDIAGNOSIS: ACUTE PULMONARY HEART DISEASE AND PULMONARY EMBOLITREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 35EDIAGNOSIS: ACUTE RHEUMATIC FEVERTREATMENT: MEDICAL MANAGEMENTCODE: 908EDIAGNOSIS: ANEURYSM OF MAJOR ARTERY OF CHEST. ABDOMEN, NECK, -UNRUPTURED OR RUPTURED NOSTREATMENT: SURGICAL MANAGEMENTCODE: 26EDIAGNOSIS: ARTERIAL EMBOLISM/THROMBOSIS: ABDOMINAL AORTA, THORACIC AORTATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 204EDIAGNOSIS: CARDIAC FAILURE: ACUTE OR RECENT DETERIORATION OF CHRONIC CARDIAC FAILURETREATMENT: MEDICALTREATMENTCODE: 98EDIAGNOSIS: COMPLETE, CORRECTED AND OTHER TRANSPOSTION OF GREAT VESSELSTREATMENT: REPAIRCODE: 97EDIAGNOSIS: CORONARY ARTERY ANOMALYTREATMENT: ANOMALOUS CORONARY ARTERY LIGATIONCODE: 309EDIAGNOSIS: DISEASES AND DISORDERS OF AORTIC VALVE NOSTREATMENT: AORTIC VALVE REPLACEMENTCODE: 210EDIAGNOSIS: DISEASES OF ENDOCARDIUM; ENDOCARDITISTREATMENT: MEDICAL MANAGEMENTCODE: 314EDIAGNOSIS: DISEASES OF MITRAL VALVETREATMENT: VALVULOPLASTY; VALVE REPLACEMENT; MEDICAL MANAGEMENTCODE: 902EDIAGNOSIS: DISORDERS OF ARTERIES: VISCERALTREATMENT: BYPASS GRAFT; SURGICAL MANAGEMENTCODE: 18EDIAGNOSIS: DISSECTING OR RUPTURED AORTIC ANEURYSMTREATMENT: SURGICAL MANAGEMENTCODE: 915EDIAGNOSIS: GANGRENE; SEVERE ATHEROSCLEROSIS OF ARTERIES OF EXTREMITIES; DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISEASETREATMENT: MEDICAL AND SURGICAL MANAGEMENT INCLUDING AMPUTATIONCODE: 294EDIAGNOSIS: GIANT CELL ARTERITIS, KAWASAKI DISEASE, HYPERSENSITIVITY ANGIITISTREATMENT: MEDICAL MANAGEMENTCODE: 450EDIAGNOSIS: HEREDITARY HEMORRHAGIC TELANGIECTASIATREATMENT: EXCISIONCODE:901EDIAGNOSIS: HYPERTENSION - ACUTE LIFE-THREATENING COMPLICATIONS AND MALIGNANT HYPERTENSION; RENAL ARTERY STENOSIS AND OTHER CURABLE HYPERTENSIONTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 111EDIAGNOSIS: INJURY TO MAJOR BLOOD VESSELS - TRUNK, HEAD AND NECK, AND UPPER LIMBSTREATMENT: REPAIRCODE: 19EDIAGNOSIS: INJURY TO MAJOR BLOOD VESSELS OF EXTREMITIESTREATMENT: LIGATIONCODE; 903EDIAGNOSIS: LIFE-THREATENING CARDIAC ARRHYTHMIASTREATMENT: MEDICAL AND SURGICAL MANAGEMENT, PACEMAKERS, CARDIOVERSION CODE: 900EDIAGNOSIS: LIFE-THREATENING COMPLICATIONS OF ELECTIVE CARDIAC AND MAJOR VASCULAR PROCEDURESTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 497EDIAGNOSIS: MULTIPLE VALVULAR DISEASETREATMENT: SURGICAL MANAGEMENTCODE: 355EDIAGNOSIS: OTHER ANEURYSM OF ARTERY - PERIPHERALTREATMENT: SURGICAL MANAGEMENTCODE: 905EDIAGNOSIS: OTHER CORRECTABLE CONGENITAL CARDIAC CONDITIONSTREATMENT: SURGICAL REPAIR; MEDICAL MANAGEMENTCODE: 100EDIAGNOSIS: PATENT DUCTUS ARTERIOSUS; AORTIC PULMONARY FISTULA - PERSISTENTTREATMENT: LIGATIONCODE: 209EDIAGNOSIS: PHLEBITIS & THROMBOPHLEBITIS, DEEPTREATMENT: LIGATION AND DIVISION; MEDICAL MANAGEMENTCODE: 914EDIAGNOSIS: RHEUMATIC PERICARDITIS; RHEUMATIC MYOCARDITISTREATMENT: MEDICAL MANAGEMENTCODE: 16EDIAGNOSIS: RUPTURE OF PAPILLARY MUSCLETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 627EDIAGNOSIS: SHOCK / HYPOTENSION - LIFE THREATENINGTREATMENT: MEDICAL MANAGEMENT; VENTILATIONCODE: 99EDIAGNOSIS: TETRALOGY OF FALLOT (TOF)TREATMENT: TOTAL REPAIR TETRALOGYCODE: 93EDIAGNOSIS: VENTRICULAR SEPTAL DEFECT - PERSISTENTTREATMENT: CLOSUREGastro-intestinal system
CODE: 920FDIAGNOSIS: ANAL FISSURE; ANAL FISTULATREATMENT: FISSURECTOMY; FISTULECTOMY; MEDICAL MANAGEMENTCODE: 41FDIAGNOSIS: ABSCESS OF INTESTINETREATMENT: DRAIN ABSCESS; MEDICAL MANAGEMENTCODE: 489FDIAGNOSIS: ACQUIRED HYPERTROPHIC PYLORIC STENOSIS AND OTHER DISORDERS OF THE STOMACH AND DUODENUMTREATMENT: SURGICAL MANAGEMENTCODE: 254FDIAGNOSIS: ACUTE DIVERTICULITIS OF COLONTREATMENT: MEDICAL AND SURGICAL MANAGEMENT, INCLUDING COLON RESECTIONCODE: 124FDIAGNOSIS: ACUTE VASCULAR INSUFFICIENCY OF INTESTINETREATMENT: COLECTOMYCODE: 337FDIAGNOSIS: AMOEBIASIS; TYPHOIDTREATMENT: MEDICAL MANAGEMENTCODE: 264FDIAGNOSIS: ANAL AND RECTAL POLYPTREATMENT: EXCISION OF POLYPCODE: 9FDIAGNOSIS: APPENDICITISTREATMENT: APPENDECTOMYCODE: 952FDIAGNOSIS: CANCER OF RETROPERITONEUM, PERITONEUM, OMENTUM & MESENTERY - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 950FDIAGNOSIS: CANCER OF THE GIT INCLUDING OESOPHAGUS, STOMACH, BOWEL, RECTUM, ANUS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 95FDIAGNOSIS: CONGENITAL ANOMALIES OF UPPER ALIMENTARY TRACT - EXCLUDING TONGUETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 214FDIAGNOSIS: OESOPHAGEAL STRICTURETREATMENT: DILATION; SURGERYCODE: 516FDIAGNOSIS: ESOPHAGEAL VARICESTREATMENT: MEDICAL MANAGEMENT; SURGICAL SHUNT; SCLEROTHERAPYCODE: 902FDIAGNOSIS: GASTRIC OR INTESTINAL ULCERS WITH HEMORRHAGE OR PERFORATIONTREATMENT: SURGERY; ENDOSCOPIC DIAGNOSIS; MEDICAL MANAGEMENTCODE: 901FDIAGNOSIS: GASTROENTERITIS AND COLITIS WITH LIFE-THREATENING HAEMORRHAGE OR DEHYDRATION, REGARDLESS OF CAUSETREATMENT: MEDICAL MANAGEMENTCODE: 6FDIAGNOSIS: HERNIA WITH OBSTRUCTION AND/OR GANGRENE; UNCOMPLICATED HERNIAS UNDER AGE 18TREATMENT: REPAIR; BOWEL RESECTIONCODE: 20FDIAGNOSIS: INTESTINAL OBSTRUCTION WITHOUT MENTION OF HERNIA; SYMPTOMATIC FOREIGN BODY IN STOMACH, INTESTINES, COLON & RECTUMTREATMENT: EXCISION; SURGERY; MEDICAL MANAGEMENTCODE: 232FDIAGNOSIS: PARALYTIC ILEUSTREATMENT: MEDICAL MANAGEMENTCODE: 498FDIAGNOSIS: PERITONEAL ADHESIONTREATMENT: SURGICAL MANAGEMENTCODE: 3FDIAGNOSIS: PERITONITIS, REGARDLESS OF CAUSETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 555FDIAGNOSIS: RECTAL PROLAPSETREATMENT: PARTIAL COLECTOMYCODE: 292FDIAGNOSIS: REGIONAL ENTERITIS; IDIOPATHIC PROCTOCOLITIS - ACUTE EXACCERBATIONS AND COMPLICATIONS ONLYTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 900FDIAGNOSIS: RUPURE OF INTRA-ABDOMINAL ORGANTREATMENT: REPAIR; SPLENECTOMY; RESECTIONCODE: 507FDIAGNOSIS: THROMBOSED AND COMPLICATED HEMORRHOIDSTREATMENT: HEMORRHOIDECTOMY; INCISIONLiver, pancreas and spleen
CODE: 325GDIAGNOSIS: ACUTE NECROSIS OF LIVERTREATMENT: MEDICAL MANAGEMENTCODE: 327GDIAGNOSIS: ACUTE PANCREATITISTREATMENT: MEDICAL MANAGEMENT, AND WHERE APPROPRIATE, SURGICAL MANAGEMENTCODE: 36GDIAGNOSIS: BUDD-CHIARI SYNDROME, AND OTHER VENOUS EMBOLISM AND THROMBOSISTREATMENT: THROMBECTOMY/LIGATIONCODE:910GDIAGNOSIS: CALCULUS OF BILE DUCT WITH CHOLECYSTITISTREATMENT: MEDICAL MANAGEMENT; CHOLECYSTECTOMY; OTHER OPEN OR CLOSED SURGERYCODE: 950GDIAGNOSIS: CANCER OF LIVER, BILIARY SYSTEM AND PANCREAS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE:255GDIAGNOSIS: CYST AND PSEUDOCYST OF PANCREASTREATMENT: DRAINAGE OF PANCREATIC CYSTCODE: 156GDIAGNOSIS: DISORDERS OF BILE DUCTTREATMENT: EXCISION; REPAIRCODE: 910GDIAGNOSIS: GALLSTONE WITH CHOLECYSTITIS AND/OR JAUNDICETREATMENT: MEDICAL MANAGEMENT; CHOLECYSTECTOMY; OTHER OPEN OR CLOSED SURGERYCODE: 743GDIAGNOSIS: HEPATORENAL SYNDROMETREATMENT: MEDICAL MANAGEMENTCODE: 27GDIAGNOSIS: LIVER ABSCESS; PANCREATIC ABSCESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 911GDIAGNOSIS: LIVER FAILURE; HEPATIC VASCULAR OBSTRUCTION; INBORN ERRORS OF LIVER METABOLISM; BILIARY ATRESIATREATMENT: LIVER TRANSPLANT, OTHER SURGERY MEDICAL MANAGEMENTCODE: 231GDIAGNOSIS: PORTAL VEIN THROMBOSISTREATMENT: SHUNTMusculoskeletal system ; Trauma nos
CODE: 353HDIAGNOSIS: ABSCESS OF BURSA OR TENDONTREATMENT: INCISION AND DRAINAGECODE: 32HDIAGNOSIS: ACUTE OSTEOMYELITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 950HDIAGNOSIS: CANCER OF BONES - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 206HDIAGNOSIS: CHRONIC OSTEOMYELITISTREATMENT: INCISION & DRAINAGECODE: 902HDIAGNOSIS: CLOSED FRACTURES/DISLOCATIONS OF LIMB BONES / EPIPHYSES - EXCLUDING FINGERS AND TOESTREATMENT: REDUCTION/RELOCATIONCODE: 85HDIAGNOSIS: CONGENITAL DISLOCATION OF HIP; COXA VARA & VALGA; CONGENITAL CLUBFOOTTREATMENT: REPAIR/RECONSTRUCTIONCODE: 147HDIAGNOSIS: CRUSH INJURIES OF TRUNK, UPPER LIMBS, LOWER LIMB, INCLUDING BLOOD VESSELSTREATMENT: SURGICAL MANAGEMENT; VENTILATION; ACUTE RENAL DIALYSISCODE:491HDIAGNOSIS: DISLOCATIONS/FRACTURES OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURYTREATMENT: MEDICAL MANAGEMENT; SURGICAL STABILISATIONCODE: 500HDIAGNOSIS: DISRUPTIONS OF THE ACHILLES / QUADRICEPS TENDONSTREATMENT: REPAIRCODE: 178HDIAGNOSIS: FRACTURE OF HIPTREATMENT: REDUCTION; HIP REPLACEMENTCODE; 445HDIAGNOSIS: INJURY TO INTERNAL ORGANSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 900HDIAGNOSIS: OPEN FRACTURE/DISLOCATION OF BONES OR JOINTSTREATMENT: REDUCTION/RELOCATION; MEDICAL AND SURGICAL MANAGEMENTCODE: 34HDIAGNOSIS: PYOGENIC ARTHRITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 901HDIAGNOSIS: TRAUMATIC AMPUTATION OF LIMBS, HANDS, FEET, AND DIGITSTREATMENT: REPLANTATION/AMPUTATIONSkin and breast
CODE: 465JDIAGNOSIS: ACUTE LYMPHADENITISTREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENTCODE: 900JDIAGNOSIS: BURNS, GREATER THAN 10% OF BODY SURFACE, OR MORE THAN 5% INVOLVING HEAD, NECK, HANDS, PERINEUMTREATMENT: DEBRIDEMENT; FREE SKIN GRAFT; MEDICAL MANAGEMENTCODE: 950JDIAGNOSIS: CANCER OF BREAST - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 954JDIAGNOSIS: CANCER OF SKIN, EXCLUDING MALIGNANT MELANOMA - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 952JDIAGNOSIS: CANCER OF SOFT TISSUE, INCLUDING SARCOMAS AND MALIGNANCIES OF THE ADNEXA-TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 349JDIAGNOSIS: CELLULITIS AND ABSCESSES WITH RISK OF ORGAN OR LIMB DAMAGE OR SEPTICEMIA IF UNTREATED; NECROTISING FASCIITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 901JDIAGNOSIS: DISSEMINATED BULLOUS SKIN DISEASE, INCLUDING PEMPHIGUS, PEMPHIGOID, EPIDERMOLYSIS BULLOSA, EPIDERMOLYTIC HYPERKERATOSISTREATMENT: MEDICAL MANAGEMENTCODE: 951JDIAGNOSIS: LETHAL MIDLINE GRANULOMATREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 953JDIAGNOSIS: MALIGNANT MELANOMA OF SKIN - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 373JDIAGNOSIS: NON-SUPERFICIAL OPEN WOUNDS - NON LIFE-THREATENINGTREATMENT: REPAIRCODE. 356JDIAGNOSIS: PYODERMA; BODY, DEEP-SEATED FUNGAL INFECTIONSTREATMENT: MEDICAL MANAGEMENTCODE: 112JDIAGNOSIS: TOXIC EPIDERMAL NECROLYSIS AND STAPHYLOCOCCAL SCALDED SKIN SYNDROME; STEVENS-JOHNSON SYNDROMETREATMENT: MEDICAL MANAGEMENTEndocrine, metabolic and nutritional
CODE: 331KDIAGNOSIS: ACUTE THYROIDITISTREATMENT: MEDICAL MANAGEMENTCODE: 951KDIAGNOSIS: BENIGN AND MALIGNANT TUMOURS OF PITUITARY GLAND WITH/WITHOUT HYPERSECRETION SYNDROMESTREATMENT: MEDICAL AND SURGICAL MANAGEMENT; RADIATION THERAPYCODE: 30KDIAGNOSIS: BENIGN NEOPLASM OF ISLETS OF LANGERHANSTREATMENT: EXCISION OF TUMOR; MEDICAL MANAGEMENTCODE: 950KDIAGNOSIS: CANCER OF ENDOCRINE SYSTEM, EXCLUDING THYROID - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 952KDIAGNOSIS: CANCER OF THYROID - TREATABLE; CARCINOID SYNDROMETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INLCUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 61KDIAGNOSIS: CONGENITAL HYPOTHYROIDISMTREATMENT: MEDICAL MANAGEMENTCODE: 902KDIAGNOSIS: DISORDERS OF ADRENAL SECRETION NOSTREATMENT: MEDICAL MANAGEMENT; ADRENALECTOMYCODE: 447KDIAGNOSIS: DISORDERS OF PARATHYROID GLAND; BENIGN NEOPLASM OF PARATHYROID GLANDTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 904KDIAGNOSIS: HYPER AND HYPOTHYROIDISM WITH LIFE-THREATENING COMPLICATIONS OR REQUIRING SURGERYTREATMENT: MEDICAL MANAGEMENT; SURGERYCODE: 31KDIAGNOSIS: HYPOGLYCEMIC COMA; HYPERGLYCEMIA; DIABETIC KETOACIDOSISTREATMENT: MEDICAL MANAGEMENTCODE: 236KDIAGNOSIS: IRON DEFICIENCY; VITAMIN AND OTHER NUTRITIONAL DEFICIENCIES - LIFETHREATENINGTREATMENT: MEDICAL MANAGEMENTCODE: 901KDIAGNOSIS: LIFE-THREATENING CONGENITAL ABNORMALITIES OF CARBOHYDRATE, LIPID, PROTEIN AND AMINO ACID METABOLISMTREATMENT: MEDICAL MANAGEMENTCODE: 903KDIAGNOSIS: LIFE-THREATENING DISORDERS OF FLUID AND ELECTROLYTE BALANCE, NOSTREATMENT: MEDICAL MANAGEMENTUrinary and male genital system
CODE: 354LDIAGNOSIS: ABSCESS OF PROSTATETREATMENT: TURP; DRAIN ABSCESSCODE: 904LDIAGNOSIS: ACUTE AND CHRONIC PYELONEPHRITIS; RENAL & PERINEPHRIC ABSCESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 903LDIAGNOSIS: ACUTE GLOMERULONEPHRITIS AND NEPHROTIC SYNDROMETREATMENT: MEDICAL MANAGEMENTCODE: 954LDIAGNOSIS: CANCER OF PENIS AND OTHER MALE GENITAL ORGAN - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 953LDIAGNOSIS: CANCER OF PROSTATE GLAND - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 950LDIAGNOSIS: CANCER OF TESTIS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 952LDIAGNOSIS: CANCER OF URINARY SYSTEM INCLUDING KIDNEY AND BLADDER - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 906LDIAGNOSIS: CONGENITAL ANOMALIES OF URINARY SYSTEM - SYMPTOMATIC AND LIFETHREATENINGTREATMENT: NEPHRECTOMY/REPAIRCODE: 901LDIAGNOSIS: END STAGE RENAL DISEASE REGARDLESS OF CAUSETREATMENT: DIALYSIS & RENAL TRANSPLANT WHERE DEPARTMENT OF HEALTH CRITERIA ARE MET ONLY (SEE CRITERIA PUBLISHED IN GPS 004-9001)CODE: 900LDIAGNOSIS: HYPERPLASIA OF THE PROSTATE, WITH ACUTE URINARY RETENTION OR OBSTRUCTIVE RENAL FAILURETREATMENT: TRANSURETHRAL RESECTION; MEDICAL MANAGEMENTCODE: 905LDIAGNOSIS: OBSTRUCTION OF THE UROGENITAL TRACT, REGARDLESS OF CAUSETREATMENT: CATHETERIZATION; SURGERY; ENDOSCOPIC REMOVAL OF OBSTRUCTING AGENT: LITHOTRIPSYCODE: 436LDIAGNOSIS: TORSION OF TESTISTREATMENT: ORCHIDECTOMY; REPAIRCODE: 43LDIAGNOSIS: TRAUMA TO THE URINARY SYSTEM INCLUDING RUPTURED BLADDERTREATMENT: CYSTORRHAPHY; SUTURE; REPAIRCODE: 289LDIAGNOSIS: URETERAL FISTULA (INTESTINAL)TREATMENT: NEPHROSTOMYCODE: 359LDIAGNOSIS: VESICOURETERAL REFLUXTREATMENT: MEDICAL MANAGEMENT; REPLANTATIONFemale reproductive system
CODE: 539MDIAGNOSIS: ABSCESSES OF BARTHOLIN'S GLAND AND VULVATREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENTCODE: 288MDIAGNOSIS: ACUTE PELVIC INFLAMMATORY DISEASETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 954MDIAGNOSIS: CANCER OF CERVIX - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 952MDIAGNOSIS: CANCER OF OVARY - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 950MDIAGNOSIS: CANCER OF UTERUS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 953MDIAGNOSIS: CANCER OF VAGINA, VULVA AND OTHER FEMALE GENITAL ORGANS NOS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY AND CHEMOTHERAPYCODE: 960MDIAGNOSIS: CERVICAL AND BREAST CANCER SCREENINGTREATMENT: CERVICAL SMEARS; PERIODIC BREAST EXAMINATIONCODE: 645MDIAGNOSIS: CONGENITAL ABNORMALITIES OF THE FEMALE GENITALIATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 266MDIAGNOSIS: DYSPLASIA OF CERVIX AND CERVICAL CARCINOMA-IN-SITU; CERVICAL CONDYLOMATATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 53MDIAGNOSIS: ECTOPIC PREGNANCYTREATMENT: SURGERYCODE: 460MDIAGNOSIS: FISTULA INVOLVING FEMALE GENITAL TRACTTREATMENT: CLOSURE OF FISTULACODE: 951MDIAGNOSIS: HYDATIDIFORM MOLE; CHORIOCARCINOMATREATMENT: D & C; HYSTERECTOMY; CHEMOTHERAPYCODE: 902MDIAGNOSIS: INFERTILITYTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 528MDIAGNOSIS: MENOPAUSAL MANAGEMENT, ANOMALIES OF OVARIES, PRIMARY AND SECONDARY AMENORRHOEA, FEMALE SEX HORMONES ABNORMALITIES NOS, INCLUDING HIRSUTISM.TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, INCLUDING HORMONE REPLACEMENT THERAPYCODE: 434MDIAGNOSIS: NON-INFLAMMATORY DISORDERS AND BENIGN NEOPLASMS OF OVARY, FALLOPIAN TUBES AND UTERUSTREATMENT: SALPINGECTOMY; OOPHORECTOMY; HYSTERECTOMY; MEDICAL AND SURGICAL MANAGEMENTCODE: 237MDIAGNOSIS: SEXUAL ABUSE, INCLUDING RAPETREATMENT: MEDICAL MANAGEMENT; PSYCHOTHERAPYCODE; 903MDIAGNOSIS: SPONTANEOUS ABORTIONTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 435MDIAGNOSIS: TORSION OF OVARYTREATMENT: OOPHORECTOMY; OVARIAN CYSTECTOMYCODE: 530MDIAGNOSIS: UTERINE PROLAPSE; CYSTOCELETREATMENT: SURGICAL REPAIRCODE: 296MDIAGNOSIS: VOLUNTARY TERMINATION OF PREGNANCYTREATMENT: INDUCED ABORTION; MEDICAL AND SURGICAL MANAGEMENTPregnancy and childbirth
CODE: 67NDIAGNOSIS: # LOW BIRTH WEIGHT (UNDER 1000g) WITH RESPIRATORY DIFFICULTIESTREATMENT: # MEDICAL MANAGEMENT NOT INCLUDING VENTILATIONCODE: 967NDIAGNOSIS: # LOW BIRTH WEIGHT (UNDER 2500 GRAMS & > 1000g) WITH RESPIRATORY DIFFICULTIESTREATMENT: MEDICAL MANAGEMENT, INCLUDING VENTILATION; INTENSIVE CARE THERAPYCODE: 71NDIAGNOSIS: BIRTH TRAUMA FOR BABYTREATMENT; MEDICAL MANAGEMENT; SURGERYCODE: 901NDIAGNOSIS: CONGENITAL SYSTEMIC INFECTIONS AFFECTING THE NEWBORNTREATMENT: MEDICAL MANAGEMENT, VENTILATIONCODE: 904NDIAGNOSIS: HAEMATOLOGICAL DISORDERS OF THE NEWBORNTREATMENT: MEDICAL MANAGEMENTCODE: 54NDIAGNOSIS: NECROTIZING ENTEROCOLITIS IN NEWBORNTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 74NDIAGNOSIS: NEONATAL AND INFANT GIT ABNORMALITIES AND DISORDERS, INCLUDING MALROTATION AND ATRESIATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 902NDIAGNOSIS: NEONATAL ENDOCRINE, METABLIC AND TOXIN-INDUCED CONDITIONSTREATMENT: MEDICAL MANAGEMENTCODE: 903NDIAGNOSIS: NEUROLOGICAL ABNORMALITIES IN THE NEWBORNTREATMENT: MEDICAL MANAGEMENTCODE: 52NDIAGNOSIS: PREGNANCYTREATMENT: ANTENATAL AND OBSTETRIC CARE NECESSITATING HOSPITALISATION, INCLUDING DELIVERYCODE: 56NDIAGNOSIS: RESPIRATORY CONDITIONS OF NEWBORNTREATMENT: MEDICAL MANAGEMENT; VENTILATIONHaematological, infectious and miscellaneous systemic conditions
CODE: 50SDIAGNOSIS: SYPHILIS - CONGENITAL, SECONDARY AND TERTIARYTREATMENT: MEDICAL MANAGEMENTCODE: 168SDIAGNOSIS: # HIV-ASSOCIATED DISEASE - FIRST ADMISSION OR SUBSEQUENT ADMISSIONSTREATMENT: # MEDICAL AND SURGICAL MANAGEMENT FOR OPPORTUNISTIC INFECTIONS / LOCALISED:MALIGNANCIESCODE: 260SDIAGNOSIS: # IMMINENT DEATH REGARDLESS OF DIAGNOSISTREATMENT: # COMFORT CARE; PAIN RELIEF; HYDRATIONCODE: 113SDIAGNOSIS: ACQUIRED HAEMOLYTIC ANAEMIASTREATMENT: MEDICAL MANAGEMENTCODE: 901SDIAGNOSIS: ACUTE LEUKAEMIAS, LYMPHOMASTREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY, RADIATION THERAPY, BONE MARROW TRANSPLANTATIONCODE: 277SDIAGNOSIS: ANAEROBIC INFECTIONS - LIFE THREATENINGTREATMENT: MEDICAL MANAGEMENT; HYPERBARIC OXYGENCODE: 48SDIAGNOSIS: ANAPHYLACTIC SHOCKTREATMENT: MEDICAL MANAGEMENT; VENTILATIONCODE: 900SDIAGNOSIS: APLASTIC ANEMIA; AGRANULOCYTOSIS; OTHER LIFE-THREATENING HERIDITARY IMMUNE DEFICIENCIES.TREATMENT: BONE MARROW TRANSPLANTATION; MEDICAL MANAGEMENTCODE: 197SDIAGNOSIS: BOTULISMTREATMENT: MEDICAL MANAGEMENTCODE: 338SDIAGNOSIS; CHOLERA; RAT-BITE FEVERTREATMENT: MEDICAL MANAGEMENTCODE: 196SDIAGNOSIS: CHRONIC GRANULOMATOUS DISEASETREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 916SDIAGNOSIS: COAGULATION DEFECTSTREATMENT: MEDICAL MANAGEMENTCODE: 246SDIAGNOSIS: CYSTICERCOSIS; OTHER SYSTEMIC CESTODE INFECTIONTREATMENT: MEDICAL MANAGEMENTCODE: 903SDIAGNOSIS: DEEP-SEATED (EXCLUDING NAIL INFECTIONS), DISSEMINATED AND SYSTEMIC FUNGAL INFECTIONSTREATMENT: MEDICAL MANAGEMENT; SURGERYCODE: 44SDIAGNOSIS: ERYSIPELASTREATMENT: MEDICAL MANAGEMENTCODE: 179SDIAGNOSIS: HEREDITARY ANGIOEDEMA; ANGIONEUROTIC ADEMATREATMENT: MEDICAL AND SURGICAL THERAPYCODE: 174SDIAGNOSIS: HEREDITARY HAEMOLYTIC ANAEMIAS (EG. SICKLE CELL); DYSERYTHROPOIETIC ANEMIA (CONGENITAL)TREATMENT: MEDICAL MANAGEMENTCODE: 201SDIAGNOSIS: HERPETIC ENCEPHALITIS; REYE'S SYNDROMETREATMENT: MEDICAL MANAGEMENTCODE: 913SDIAGNOSIS: IMMUNE COMPROMISE NOS AND ASSOCIATED LIFE-THREATENING INFECTIONS NOSTREATMENT: MEDICAL MANAGEMENTCODE' 912SDIAGNOSIS: LEPROSY AND OTHER SYSTEMIC MYCOBACTERIAL INFECTIONS, EXCLUDING TUBERCULOSISTREATMENT: MEDICAL MANAGEMENTCODE: 336SDIAGNOSIS: LEPTOSPIROSIS; SPIROCHAETAL INFECTIONS NOSTREATMENT: MEDICAL MANAGEMENTCODE: 252SDIAGNOSIS: LIFE-THREATENING ANAEMIA NOSTREATMENT: MEDICAL MANAGEMENT; TRANSFUSIONCODE: 908SDIAGNOSIS: LIFE-THREATENING CONDITIONS DUE TO EXPOSURE TO THE ELEMENTS, INCLUDING HYPO AND HYPERTHERMIA; LIGHTNING STRIKES]TREATMENT: MEDICAL MANAGEMENTCODE: 907SDIAGNOSIS: LIFE-THREATENING RICKETTSIAL AND OTHER ARTHROPOD-BORNE DISEASESTREATMENT: MEDICAL MANAGEMENTCODE: 172SDIAGNOSIS: MALARIA; TRYPANOSOMIASIS; OTHER LIFE-THREATENING PARASITIC DISEASETREATMENT: MEDICAL MANAGEMENTCODE: 904SDIAGNOSIS: METASTATIC INFECTIONS; SEPTICEMIATREATMENT: MEDICAL MANAGEMENTCODE: 910SDIAGNOSIS: MULTIPLE MYELOMA AND CHRONIC LEUKAEMIASTREATMENT: MEDICAL MANAGEMENT; CHEMOTHERAPYCODE: 247SDIAGNOSIS: POISONING BY INGESTION, INJECTION, AND NON-MEDICINAL AGENTSTREATMENT: MEDICAL MANAGEMENTCODE: 911SDIAGNOSIS: SEXUALLY TRANSMITTED DISEASES WITH SYSTEMIC INVOLVEMENT NOT ELSWHERE SPECIFIEDTREATMENT: MEDICAL MANAGEMENTCODE: 128SDIAGNOSIS: TETANUS; ANTHRAX; WHIPPLE’S DISEASETREATMENT: MEDICAL MANAGEMENTCODE: 122SDIAGNOSIS: THALASSEMIA AND OTHER HEMOGLOBINOPATHIES - TREATABLETREATMENT: MEDICAL MANAGEMENT; BONE MARROW TRANSPLANTCODE: 316SDIAGNOSIS: TOXIC EFFECT OF GASES, FUMES, AND VAPORSTREATMENT: MEDICAL THERAPYCODE: 11SDIAGNOSIS: TUBERCULOSISTREATMENT: DIAGNOSIS AND ACUTE MEDICAL MANAGEMENT; SUCCESSFUL TRANSFER TO MAINTENANCE THERAPY IN ACCORDANCE WITH DOH GUIDELINESCODE: 937SDIAGNOSIS: TUMOUR OF INTERNAL ORGAN (EXCLUDES SKIN): UNKNOWN WHETHER BENIGN OR MALIGNANTTREATMENT: BIOPSYCODE: 15SDIAGNOSIS: WHOOPING COUGH, DIPTHERIATREATMENT: MEDICAL MANAGEMENTMental illness
CODE: 182TDIAGNOSIS: ABUSE OR DEPENDENCE ON PSYCHOACTIVE SUBSTANCETREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEARCODE: 910TDIAGNOSIS: ACUTE DELUSIONAL MOOD, ANXIETY, PERSONALITY, PERCEPTION DISORDERS AND ORGANIC MENTAL DISORDER CAUSED BY DRUGS;TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYSCODE: 901TDIAGNOSIS: ACUTE STRESS DISORDER ACCOMPANIED BY RECENT SIGNIFICANT TRAUMA, INCLUDING PHYSICAL OR SEXUAL ABUSETREATMENT: HOSPITAL ADMISSION FOR MEDICAL/PSYCHOTHERAPY UP TO 3 DAYS; COUNSELLINGCODE: 910TDIAGNOSIS: ALCOHOL WITHDRAWAL DELIRIUM; ALCOHOL INTOXICATION DELIRIUMTREATMENT: HOSPITAL BASED MANAGEMENT UP TO 3 DAYS LEADING TO REHABILITATIONCODE: 908TDIAGNOSIS: ANOREXIA NERVOSA AND BULIMIA NERVOSATREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEARCODE: 903TDIAGNOSIS: ATTEMPTED SUICIDE, IRRESPECTIVE OF CAUSETREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYSCODE: 184TDIAGNOSIS: BRIEF REACTIVE PSYCHOSISTREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEARCODE: 910TDIAGNOSIS: DELIRIUM: AMPHETAMINE, COCAINE, OR OTHER PSYCHOACTIVE SUBSTANCETREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYSCODE: 902TDIAGNOSIS: MAJOR AFFECTIVE DISORDERS, INCLUDING UNIPOLAR AND BIPOLAR DEPRESSIONTREATMENT: HOSPITAL-BASED MEDICAL MANAGEMENT UP TO 3 WEEKS/YEAR; ELECTRO CONVULSIVE THERAPYCODE: 907TDIAGNOSIS: SCHIZOPHRENIC AND PARANOID DELUSIONAL DISORDERSTREATMENT: HOSPITAL-BASED MEDICAL MANAGEMENT UP TO 3 WEEKS/YEARCODE: 909TDIAGNOSIS: TREATABLE DEMENTIATREATMENT: ADMISSION FOR INITIAL DIAGNOSIS; MANAGEMENT OF ACUTE PSYCHOTIC SYMPTOMS - UP TO 1 WEEKExplanatory notes and definitions to Annexure A
1)Interventions shall be deemed hospital-based where they require:- An overnight stay in hospital.or- The use of an operating theatre together with the administration of a general or regional anaesthetic.or- The application of other diagnostic or surgical procedures that carry a significant risk of death, and consequently require on-site resuscitation and/or surgical facilities.or- The use of equipment, medications or medical professionals not generally found outside of hospitals.2)Where the treatment component of a category in Annexure A is stated in general terms (i.e. “medical management” or "surgical management", it should be interpreted as referring to prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition. Where significant differences exist between Public and Private sector practices, the interpretation of the Prescribed Minimum Benefits should follow the predominant Public Hospital practice, as outlined in the relevant provincial or national public hospital clinical protocols, where these exist. Where clinical protocols do not exist, disputes should be settled by consultation with provincial health authorities to ascertain prevailing practice. The following interventions shall however be excluded from the generic medical / surgical management categories unless otherwise specified:iii)Bone marrow transplantation / rescueiv)Mechanical ventilationv)Hyperbaric oxygen therapyvii)Treatments, drugs or devices not yet registered by the relevant authority in the Republic of South Africa3)“Treatable" cancers. In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:i)they involve only the organ of origin, and have not spread to adjacent organsii)there is no evidence of distant metastatic spreadiii)they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organiv)or, if points i. to iii. do not apply, there is a well demonstrated five year survival rate of greater than 10% for the given therapy for the condition concerned4)Tumour chemotherapy with or without bone marrow transplantation and other indications for bone marrow transplantationThese are included in the prescribed minimum benefits package only where Annexure A explicitly mentions such interventions. Management may include a first full course of chemotherapy (including, if indicated, induction, consolidation and myeloablative components). Where specified in terms of Annexure A, this may be followed by bone marrow transplantation/rescue, according to tumour type and prevailing practice. The following conditions would also apply to the bone marrow transplantation component of the prescribed minimum benefits:i)the patient should be under 60 years of ageii)allogeneic bone marrow transplantation should only be considered where there is an HLA matched family donoriii)the patient should not have relapsed after a previous full course of chemotherapyiv)(points i. and ii. shall also apply to bone marrow transplantation for non-malignant diseases)5)Solid organ transplantsThe prescribed minimum benefits Annexure includes solid organ transplants (liver, kidney and heart) only where these are provided by Public hospitals in accordance with Public sector protocols and subject to public sector waiting lists.6)In certain cases, specified categories shall take precedence over others present. Such “overriding" categories are preceded by the sign "#" in their descriptions within Annexure A. For Example, where someone is suffering from pneumonia and HIV, because the HIV category (168S) is an overriding category, the entitlements guaranteed by the 'pneumonia' category (903D) are overridden.7)Hospital treatment where the diagnosis is uncertain and/or admission for diagnostic purposesUrgent admission may be required where a diagnosis has not yet been made. Certain categories of prescribed minimum benefits are described in terms of presenting symptoms, rather than diagnosis, and in these cases, inclusion within the prescribed minimum benefits may be assumed without a definitive diagnosis. In other cases, clinical evidence should be regarded as sufficient where this suggests the existence of a diagnosis that is included within the package. Medical schemes may, however, require confirmatory evidence of this diagnosis within a reasonable period of time, and where they consistently encounter difficulties with particular providers or provider networks, such problems should be brought to the attention of the Council for Medical Schemes for resolution.8)NOS - not otherwise specifiedAnnexure B
Limitation on assets to be held in the Republic
Item | | Categories or kinds of assets | Maximum percentage of aggregate fair value of total assets of scheme |
---|
1. | (a) Inside the Republic— |
Deposits and balances in current and savings accounts with a bank or a mutual bank, including negotiable deposits, and money market instruments in terms of which such a bank or mutual bank is liable. Paid-up shares of a mutual bank, or deposits and savings accounts with the Post Office savings bank, as well as margin deposits with SAFEX: | 100% |
Per bank | 20% |
Per mutual bank | 20% |
Post Office Savings Bank | 20% |
SAFEX | 5% |
Territories outside the Republic | 15% |
Deposits and balances in current and savings accounts with a bank including negotiable deposits and money market instruments in terms of which such a bank is liable | 2.5% |
Krugerrands |
1. | Bills, bonds and securities issued or guaranteed by and loans to or guaranteed by— |
(a) Inside the Republic— |
| (i) A local authority authorised by law to levy rates upon immovable property | 100% |
—per local authority | 20% |
(ii) Development Boards established under the Black communities Development Act, 1984 (Act No. 4 of 1984) | 20% |
(iii) Rand Water Board | 20% |
(iv) Eskom | 20% |
(v) Land and Agricultural Bank of South Africa | 20% |
(vi) Local Authorities Loans Fund Board | 20% |
(vii) SA Transport Services | 20% |
(a) Territories outside the Republic— |
the foreign Government concerned | 15% |
1. | Bills, bonds and securities issued by and loans to an institution in the Republic, which bills, bonds, securities and loans the Council approved in terms of section 19(1)(h) of the Act before the deletion of that section by section 8(a) of the Act No. 53 of 1989, and also bills, bonds and securities issued by and loans to an institution in the Republic, which institution the Council likewise approved before such deletion | 100% |
—per institution | 20% |
2. | Bills, bonds and securities issued by the government of or by a local authority in a territory other than the Republic, which territory the Council approved in terms of section 19(1)(I) of the Act before the deletion of that section by section 8(a) of Act No. 53 of 1989, and also bills, bonds and securities issued by an institution in such an approved territory, which institution the Council likewise approved before such deletion | 100% |
—per authority | 20% |
3. | immovable property and claims secured by mortgage bonds thereon. Units in unit trust schemes in property shares and shares in, loans to and debentures, both convertible and non-convertible, of property companies | 20% |
(a) inside the Republic | 20% |
—per single property, property company or property development project | 5% |
(b) territories outside the Republic | 10% |
—per single property, property company or property development project | 5% |
1. | Preference and ordinary shares in companies excluding shares in property companies. ertible debentures, whether voluntarily or compulsorily convertible and units in equity unit trust mes which objective is to invest their assets mainly in shares | 75% |
These investments are subject to the following limitations: |
(a) inside the Republic | 75% |
| (i) Unlisted shares, unlisted convertible debentures and shares and convertible debentures listed in the Development Capital sector of the Johannesburg Stock Exchange | 5% |
(ii) Shares and convertible debentures listed on the Johannesburg Stock Exchange other than the Development Capital sector | 75% |
| (a) Per one company with a market capitalisation of R2 000 million or less | 10% |
(b) per one company with a market capitalisation of more than R2 000 million | 15% |
(a) territories outside the Republic— |
Preference and ordinary shares in companies, convertible debentures, whether voluntarily or compulsorily convertible | 15% |
| (i) unlisted shares and unlisted convertible debentures | 2.5% |
(ii) shares and convertible debentures listed on any recognised foreign exchange |
| (a) per one company with a market capitalisation of R2 000 million or less | 15% |
(b) per one company with a market capitalisation of more than R2 000 million | 10% |
1. | Listed and unlisted debentures, units in a unit trust scheme with the objective to invest e generating securities and inside the Republic any secured claims against an insurance any in terms of a long-term policy of insurance | 10% |
1. | Computer equipment, furniture and other office equipment, as well as motor vehicles, ct to the following limitation: |
| (a) Computer equipment | 5% (10% by exemption) |
(b) Other equipment, as well as motor vehicles | 2,5% (5% by exemption) |
(b)Annexure C
Report of the independent auditors of ________________ (name of administrator) to the Registrar of Medical Schemes in compliance with Regulation 25 under the Medical Schemes Act, 1998
1.We have reviewed the [proposed] system of internal financial control of ________ (name of administrator)/[that ________ (name of administrator) intends to Implement from ________].2.The [implementation and] maintenance of an adequate system of internal financial control [are] is the responsibility of the directors/partners/sole proprietor. Our responsibility is to report on whether or not, based on our review, anything has come to our attention that would indicate that the [proposed] system of internal financial control is not adequate for the size and complexity of the business of the medical scheme or medical schemes [to be] administered.3.ScopeWe conducted our review in accordance with the statement of South African Auditing Standards applicable to review engagements. This standard requires that we plan and perform the review to obtain moderate assurance with regard to the [proposed] system of internal financial control. A review is limited primarily to inquiries of personnel of the administrator, inspection of evidence and observation of, and enquiry about, the operation of the internal control procedures for a small number of transactions. [A review is limited primarily to inquiries of personnel of the administrator about the proposed operation of the system of internal financial control and inspection of related evidence.]4.Inherent limitationsBecause of the inherent limitations of a system of internal financial control, including concealment through collusion or forgery, it is possible that errors and irregularities may occur and not be detected.A review is not designed to detect all weaknesses in the system of internal financial control as it is not performed continuously throughout the period and the tests performed are on a sample basis. [A review is not designed to detect all weaknesses in the proposed system of internal financial control.][As the proposed system of internal financial control has not yet been implemented, we do not provide any assurance as to whether or not the system will operate adequately.]5.Any projections of the evaluation of the system of internal financial control to future periods is subject to the risk that the controls may become inadequate because of changes in conditions, or that the degree of compliance with them may deteriorate.6.Also, a review does not provide all the evidence that would be required in an audit, thus the level of assurance provided is less than given in an audit We have not performed an audit and, accordingly, we do not express an audit opinion.7.(b) Review opinionBased on our review, nothing of significance has come to our attention that causes us to believe that the [proposed] system of internal financial control is not adequate for the size and complexity of the business of the medical scheme or schemes [to be] administered.Name ________________Registered Accountants and Auditors ________________Chartered Accountants (SA) ________________Date ____________Address ____________Report of the independent auditors of ________________ (name of administrator) to the Registrar of Medical Schemes in compliance with Regulation 25 under the Medical Schemes Act, 1998
A. Annual financial statements
1.We have audited the attached annual financial statements of ________________ (name of administrator) (“the administrator”) set out on pages ________________ to ________________ for the year ended ______ The annual financial statements are the responsibility of the directors/partners/sole proprietor. Our responsibility is to express an opinion on these financial statements based on our audit.2.ScopeWe conducted our audit in accordance with statements of south african auditing Standards. Those standards require that we plan and perform the audit to obtain reasonable assurance that the annual financial statements are free of material misstatement. An audit includes:2.1examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements;2.2assessing the accounting principles used and significant estimates made by management; and2.3evaluating the overall financial statement presentation.We believe that our audit provides a reasonable basis for our opinion.3.Audit opinionIn our opinion the annual financial statements fairly present, in all material respects, the financial position of the administrator at ____________ and the results of its operations and cash flows for the year then ended in accordance with generally accepted accounting practice and in the manner required by the Companies Act, 1973 (include where appropriate).B. Consideration of the system of internal financial controls
4.in planning and performing the above-mentioned audit, we considered the system of internal financial control of the administrator in order to determine our audit procedures for the purpose of expressing our audit opinion on the annual financial statements, not to provide assurance on the system of the internal financial control.5.The directors/partners/sole proprietor of ____________ (name of the administrator) are/is responsible for establishing and maintaining an effective system of internal financial control. In fulfilling this responsibility, estimates and judgements by the directors/partners/sole proprietor are required to assess the expected benefits and related costs of internal financial control policies and procedures. Two of the objectives of a system of internal financial control are to provide the directors/partners/sole proprietor with reasonable, but not absolute, assurance that assets are safeguarded against loss from unauthorised use or disposition and that transactions are executed in accordance with their/his/her authorisation and recorded properly to permit preparation of annual financial statements in conformity with generally accepted accounting practice.6.Because of the inherent limitations of a system of internal financial control, it is possible that errors or irregularities may occur and not be detected. Furthermore, any projection of the evaluation of a system of internal financial control to future periods is subject to the risk that the procedures may become inadequate because of changes in circumstances, or that the degree of compliance with them may deteriorate.7.Our consideration of the system of internal financial control would not necessarily disclose all matters in the system that might be material weaknesses. A material weakness is a condition in which the design or operation of the specific internal financial control does not reduce to a relatively low level the risk that errors or irregularities in amounts that would be material in relation to the annual financial statements being audited, may occur and not be detected within a timely period by employees in the normal performance of their assigned functions.8.However, based on our consideration of the system of internal financial control for purposes of our audit, nothing of significance has come to our attention that causes us to believe that the financial record keeping and the system of internal financial control are not adequate for the size and complexity of the business the administrator is presently conducting. All changes to the system of internal financial control that came to our attention during the course of our audit have been recorded in writing.9.This report is intended solely for the use of the Registrar of Medical Schemes and is not to be distributed to other parties.Name ________________Registered Accountants and Auditors ________________Chartered Accountants (SA) ________________Date ________Address ________Annexure D (For completion on letterhead of Administrator)
Management representation letter to the Registrar of Medical Schemes in compliance with Regulation 25 under the Medical Schemes Act, 1998
This representation letter is provided in connection with the financial statements of ________ (name of the administrator) for the year ended ________ (date) to enable the Registrar to evaluate whether or not ________ (name of the administrator) has complied with the Medical Schemes Act and related regulations.We confirm, to the best of our knowledge and belief, the following representations:1.We had ________ (quantity) registered funds under our administration at the year-end.2.The fidelity guarantee and professional indemnity insurance cover is adequate to cover the risks of losses due to fraud, dishonesty and negligence.3.We deposited the moneys of the medical schemes under our administration in the bank accounts of the schemes on no later than the business day following the receipt of the schemes' moneys.4.No changes in ownership, directors, members or shareholders having the effect of a de facto change of control took place during the year ended ____________ (date), without the approval of the Registrar.5.Administration agreements entered into with medical schemes during the year ended ________ are in writing and conform to regulation 18.6.The following administration agreements were terminated during the year ended ________ (date) and in respect of them, regulation 19 have been complied with:7.For the year ended ____________, we have maintained a register of documents of title in our safe custody as contemplated in regulation 24. Furthermore, all these assets are held in the names of the respective medical schemes.8.We conducted the business in terms of the Act, the regulations, the agreements with medical schemes and the rules of these medical schemes.9.The administration business is maintained in a financially sound condition as contemplated in regulation 22.10.The system of internal control is adequate for the size and complexity of the business.11.We believe that the business will continue in operational existence for the foreseeable future.________________Managing Director________________Financial Director