Correct pricing and invoicing starts with good knowledge and application of the nomenclature. In this news article we therefore share 3 important insights and numerous examples for correctly applying the nomenclature as a healthcare institution.

 

It is crucial for every healthcare institution that the nomenclature is used without errors. It is the basis for correct pricing and invoicing. And that is the basis of a financially healthy policy. Did you know that eCoNoDat ® is an indispensable tool for this? This user-friendly database includes the integral nomenclature. And thus always offers the most complete and up-to-date information.

 

INSIGHT 1 - Check the different regulations

 

If you want to charge different numbers during the same treatment or treatment period, check the different regulations. This may be the general regulations (Article 1 or Article 10 of the nomenclature), specific regulations applicable to the article, an application rule in another article or interpretation rules.

 

  • In the application rules you can find information about when a service is reimbursed. Unfortunately, they are not always in the same place. Therefore, when checking the nomenclature, you should always read the entire article, as it may be right after the performance, at the end or even in another article. These application rules can contain anything such as the capacity of the provider, age of the patient, waiting times, etc.
  • There can also be non-cumulative rules . These rules, like the application rules, are located in the article itself or in a separate article.
  • In addition, there is also pseudonomenclature . You can find this in the circulars, agreements or in the magnetic tape instructions.
  • Finally, you should also read the interpretation rules that clarify the nomenclature. These are official answers to questions asked to the RIZIV and are published per Royal Decree.

 

Do you discover special characters such as *, **, °, ^ or ^^ in the description? These are not typos, but these have meaning.

 

INSIGHT 2 – View provider competency

 

In addition to the various regulations, it is important to look at the competence of the provider . You can determine this competence through the competence code granted by the RIZIV. In addition, a provider may also have an attribute such as intensivist. Every doctor is free to perform a service for which he or she believes he or she is competent, but not all services are invoiced.

 

EXAMPLE

A physician specialist in emergency medicine (authority code 900) may perform a pleurotomy (227496 -227500) if he has mastered this technique, but he cannot charge for this. A doctor with authorization code 170 can invoice this without any problem.

 

Correct reading of the application rules, and not just for the article in question, also plays a major role.

 

EXAMPLE

For the provision 471553-471553 (Article 20) you can also find an application rule in Article 26 (§ 4. The provisions nos. 220135 - 220146, 239035 - 239046, 244252 - 244263, 300252 - 300263, 460154 - 4 60165, 460176 - 460180 , 460191 - 460202, 460235 - 460246, 460250 - 460261, 460272 - 460283, 460294 -460305, 469416 - 469420, 469431 - 469442, 469453 - 46 9464, 469475 - 469486, 469490 - 469501, 469512 - 469523, 469534 - 469545, 471553 - 471564, 471715 - 471726, 471796 - 471800, 472393 -472404, 474036 - 474040, 474095 - 474106, 474132 - 474143, 474154 - 474165, 474 191 - 474202, 474213 - 474224, 474250 - 474261, 474272 - 474283, 474294 -474305 , 474331 - 474342, 474353 - 474364, 474390 - 474401, may also be charged by a specialist doctor or candidate specialist on call who complies with the provisions of §3, when they are carried out under the conditions provided for in Article 26, § 5.).

 

This means that the stated services (of which 471553 is one) may be performed by a doctor with the qualifications 100,109,170, 580, 580, 800 and 900 under certain circumstances. These circumstances are on-call and the provision must be carried out urgently during the weekend, public holiday or night.

 

If you are reading an article, read the section heading carefully .

 

EXAMPLE

Can performance 295315-295326: collar be invoiced by a doctor with qualifications 589: doctor specialist in internal medicine and emergency medicine?

 

No, because performance 295315 belongs to article 14k. In Article 15 § 1 you can find an application rule that stipulates: The services that belong to the other specialty listed in the same article are in any case considered related to one of the specializations listed in Article 14 a) to m). Consequently, a doctor with license code 589 (internal medicine) does not meet the conditions.

 

It may be interesting to take a look at Article 3 (Technical medical services). Art. 3. Chapter III. Ordinary medical care, Section 1. – Technical medical services, §1. A. Are considered ordinary benefits, chargeable by any doctor, I. Other benefits than those relating to clinical biology, dressings and devices other than plaster casts or orthopedic devices. The provision 145250-145261 could qualify for this.

 

For the group of external pathology we talk about connexity . This means that a provision from a discipline other than that of the doctor may be provided to this doctor's own patients.

 

INSIGHT 3 – Don't forget anything during surgical procedures

 

If a surgical procedure is involved: do not forget to charge anything. Consider, among other things, anesthesia, equipment, accreditation, urgency, supervision, etc. Accreditation can be a separate number depending on the doctor's competence.

 

If a patient is admitted to a hospital, a fixed daily allowance is provided for the medical follow-up of these patients by the supervising doctor. When having a surgical procedure, you also have to take immunity into account. This means that for a surgical procedure, supervision is included for 5 days starting from the day of the procedure.

 

Also take operating regions into account.

  • If it concerns an operation in the same operating area, only the main operation may be charged at 100%. The main operation is the one with the highest value.
  • If this is performed in different operating areas, the main processing is at 100% and the additional processing is at 50% (unless the description of the provision or application rules stipulate otherwise).

 

In certain cases you must provide the treated member.

 

Surgical services of a relative value ≥ K120, N 200 or I 200, which are provided by an accredited medical specialist, entitle you to charge an accreditation fee (318916-318920).

 

For surgical assistance during surgical services of which the relative value is equal to or higher than K 120 or N 200 or I 200, the fixed fee is set at 10% of the relative value of the provision provided.

 

EXAMPLE

Surgical intervention by an accredited doctor.

  • K 225 = main operation = K 225 = 100% + 10% operative assistance
  • K70 = K70/2 = 50%
  • K 120 = K120/2 = 50% + 10% surgical assistance
  • K 80 = additional operation (same operating region) = 0
  • Accreditation: 318916-318920

 

It may happen that the implant or material still needs to be invoiced additionally. The description of the procedure may not mention the implant or the material cost. The implant or material comes from the pharmacy and it sometimes happens that people forget to charge for this.

 

EXAMPLE

236025: Revascularization of a large intrathoracic blood vessel by endarterectomy, endoaneurysmorrhaphy, pontage or resection with grafting or anastomosis. For this service you must charge a material (161431-161442: Hybrid thoracic aortic endoprosthesis: 10 cm or more with branched or non-branched vascular graft used during the deliveries 229014-229025, 229316-229320, 229530-229541, 229596-229600 , 229272-229283, 236014-236025, 236036-236040 or 236051-236062 of the nomenclature).

 

It may also happen that you have different options with the implant

or material lump sum.

 

EXAMPLE

257014-257025: Simple total thyroidectomy or partial thyroidectomy. This provision can be done endoscopically or during open surgery. Depending on how the procedure is performed, you will need to charge the corresponding number (154114-154125 (endoscopic route) or 154136-154140 (closed surgery)).

 

Always up-to-date information with eCoNoDat ®

In a number of clear screens and with useful filters, eCoNoDat ®  offers you all the information per nomenclature number. For each number you have a brief description, the applicable rates and reimbursement rates, and the qualifications for providers and healthcare institutions. The relevant legislation is linked to each nomenclature number. In short, you have all the legal documents to carry out correct pricing and invoicing. Even more, we keep a historical overview. You can easily look up what the applicable legislation and applicable rates were in a certain period in the past.

 

 

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