Input Case
Patient: Emily Chen (BON-99887766) | Surgeon: Dr. James Anderson (General Surgery) | Scheme: Bonitas BonEssential
DISCHARGE SUMMARY AND SCHEME SUBMISSION PATIENT: Emily Chen, 28-year-old female ADMISSION DATE: 12 December 2024 DISCHARGE DATE: 15 December 2024 MEDICAL SCHEME: Bonitas BonEssential ADMISSION DIAGNOSIS: Acute appendicitis DISCHARGE DIAGNOSIS: 1. Acute gangrenous appendicitis with localized peritonitis (K35.31) 2. Paralytic ileus, post-operative (K56.0) PRINCIPAL PROCEDURE: Open appendectomy (47600) HISTORY OF PRESENT ILLNESS: 28-year-old female presented to emergency department with 24-hour history of periumbilical pain that migrated to right iliac fossa. Associated with nausea, vomiting x 2, and anorexia. No urinary symptoms. LMP 2 weeks ago. Urine pregnancy test negative. EMERGENCY DEPARTMENT FINDINGS: - Temp: 38.2C, HR: 102/min, BP: 118/72mmHg - Tender RIF with guarding and rebound tenderness - Rovsing sign positive - Psoas sign positive - WCC: 16.2 x 10^9/L with left shift CT ABDOMEN (performed same day): - Dilated appendix 12mm diameter - Surrounding fat stranding - Small amount of free fluid in pelvis - No appendicolith identified - Impression: Acute appendicitis with possible perforation OPERATIVE DETAILS: Procedure: Open appendectomy via McBurney incision Surgeon: Dr. James Anderson Anesthetist: Dr. Patrick O'Brien Date: 12 December 2024 Duration: 45 minutes Findings: - Gangrenous appendix with perforation at tip - Localized purulent peritonitis, ~50ml turbid fluid - No abscess formation - Caecum healthy Procedure: 1. McBurney incision 2. Peritoneum opened, turbid fluid aspirated 3. Appendix delivered, mesoappendix ligated 4. Appendix base double ligated and divided 5. Stump inverted with purse string (optional) 6. Peritoneal lavage with 2L warm saline 7. Wound closed in layers, no drain Specimen: Appendix sent for histology POST-OPERATIVE COURSE: Day 1: Paralytic ileus, NG tube inserted, IV fluids Day 2: Bowel sounds returned, NG removed, clear fluids tolerated Day 3: Progressed to soft diet, mobilizing well, afebrile Day 4: Discharged on oral antibiotics HISTOLOGY (Final): - Acute gangrenous appendicitis with transmural inflammation - Perforation confirmed - No evidence of malignancy DISCHARGE MEDICATIONS: 1. Augmentin 875/125mg BD x 7 days 2. Paracetamol 1g QID PRN 3. Tramadol 50mg QID PRN CODES FOR SUBMISSION: SURGICAL: - 47600: Appendectomy (open) - 0011: Emergency modifier HOSPITAL: - Ward fees: 3 days general ward - Theatre fees - Consumables INVESTIGATIONS: - CT Abdomen with contrast: 5870 - Full blood count: 3779 - Urea and electrolytes: 4013 - Histology examination: 4431 ANAESTHESIA: - General anaesthesia: Base units + time units - ASA II physical status PMB CLASSIFICATION: This is a PMB (Prescribed Minimum Benefit) condition under the following: - Emergency medical condition - DTT list condition FOLLOW-UP: Surgical outpatient clinic in 2 weeks
Medical Scheme Submission Summary
Patient: Emily Chen | Member ID: BON-99887766 | Scheme: Bonitas BonEssential
Beneficiary & Provider Details
Beneficiary
Emily Chen
DOB: 1996-11-30
Member No: BON-99887766
DOB: 1996-11-30
Member No: BON-99887766
Provider
Dr. James Anderson
Specialty: General Surgery
Practice No: MP0567890
Specialty: General Surgery
Practice No: MP0567890
Diagnosis and PMB Indicator
| ICD-10 Code | Description | PMB Status | Confidence |
|---|---|---|---|
| K35.31 | Acute gangrenous appendicitis with localized peritonitis | PMB 9F | 98% |
| K56.0 | Paralytic ileus | PMB 232F | 95% |
K35.31: Patient presented with gangrenous appendix and peritonitis confirmed by histology. While K35.31 is the specific ICD-10, it clinically falls under the PMB 9F parent codes K35.3/K35.8 (Appendicitis).
Suggested: K35.3 - Parent code explicitly listed in PMB 9F definition to ensure automatic scheme identification.
Warning: K35.31 is not explicitly listed in the provided PMB lookup list, but falls under the hierarchy of K35.3 (PMB 9F). Rejection risk if scheme uses strict string matching.
K56.0: Post-operative complication requiring medical management (NG tube, IV fluids) as documented in discharge summary.
Proposed/Performed Itemisation (RPL)
| RPL Code | Description | Linked ICD-10 | Modifiers |
|---|---|---|---|
| 1675 | Appendicectomy | K35.31, K35.3 | 0011 |
| 5870 | CT Abdomen with contrast | K35.31 | - |
1675: Code Warning
- Provider used code 47600 (CPT) in submission. This must be converted to RPL 1675 for South African medical scheme billing.
PMB Assessment
Overall Eligibility:eligible
PMB Eligible Conditions
9F - Appendicitis
Linked ICD-10: K35.3 | Treatment: Appendectomy
Linked ICD-10: K35.3 | Treatment: Appendectomy
232F - Paralytic ileus
Linked ICD-10: K56.0 | Treatment: Medical management
Linked ICD-10: K56.0 | Treatment: Medical management
| Diagnosis | Treatment | Procedure | Status | Reason |
|---|---|---|---|---|
| K35.31 | Appendectomy | 1675 | valid | Standard of care for acute gangrenous appendicitis. |
Scheme Considerations
- Bonitas BonEssential is a hospital plan. This admission is a medical emergency, mandating full funding at cost for PMB conditions.
- Emergency modifier 0011 is justified due to 'Acute abdomen' presentation and risk of perforation (confirmed intra-op).
Pre-Authorization Requirements
- Retrospective authorization required due to emergency admission.
- Submit histology report (4431) to confirm PMB diagnosis and prevent funding from savings/day-to-day.
Tariff Analysis
| Code | Description | Base Value | Final Value |
|---|---|---|---|
| 1675 | Appendicectomy | Scheme Rate | Scheme Rate |
| 0011 | Emergency Modifier (45 mins) | 0 units | 24 units |
Base units for procedure 1675 are not defined in the reference set. Total estimated total reflects only the modifier value available.
Modifier 0011 calculation: 45 minutes operating time = 2 x 12.00 unit blocks = 24.00 units.
Billing Guidance
Recommendations
- Replace CPT code 47600 with RPL code 1675.
- Submit ICD-10 K35.3 (Acute appendicitis with localised peritonitis) as primary to align strictly with PMB 9F list, with K35.31 as secondary or refining code.
- Explicitly state 'Emergency Procedure' on the claim to support Modifier 0011 and full PMB funding.
- Include theatre time (start/end) on the invoice.
| Potential Issue | Severity | Mitigation |
|---|---|---|
| Code Discrepancy | high | Do not bill 47600; use 1675. |
| PMB Code Match | medium | K35.31 is valid but not on the strict list. Map to K35.3 for claims processing. |
Required Attachments
- Operative Report indicating 45 min duration.
- Histology Report confirming gangrenous appendicitis.
- Motivation letter for PMB funding if short-paid (citing Regulation 8 for emergency).
Submission Instructions
- Mark submission as 'In-Hospital', 'Emergency', and 'PMB'.
- Ensure Anesthetist (Dr. O'Brien) and Surgeon (Dr. Anderson) codes align regarding time-based modifiers.
MedCascade provides billing assist only and does not submit claims. This summary is provided to help you prepare a submission-ready packet for your medical scheme.
Generated by MedCascade | Sample data | Not medical advice