Newsletter: November 2018

Introduction to The Hospital Dietitians Interest Group (HDIG)

The HDIG was formed in 2010 for the purpose of advocating on behalf of dietitians working in the hospital environment. HDIG focusses on interacting with relevant stakeholders in the healthcare sector to protect and promote the interests of hospital-based dietitians and raise awareness of the important role of the dietitian in the clinical management of hospitalised patients.

HDIG also aims to enhance awareness of the scope of practice of the hospital dietitian and ensure that this key professional practice area is well-positioned through the current changes occurring in the South African healthcare structure and enjoys an enhanced career profile in future.

In this newsletter, we will be updating you on some of the ongoing issues affecting hospital dietitians that HDIG continues to represent and advocate for.

Dietitians Tariffs/Billing Project

We are working together with ADSA to ensure that all medical schemes adopt the revised ADSA tariff structure as outlined in the newsletter of August 2018. Thank you to those who completed the Practice Cost Survey advertised in the previous newsletter. HDIG is very grateful for the increased response following the previous appeal and there was a particular increase in responses after our appeal in the Free State – thank you!

We were required to obtain 40 surveys in order to complete our data set for use in billing advocacy with medical schemes. Currently, the total is 35 responses – good job. PLEASE can we make one final request of you to contribute to the survey by going to the Practice Cost Survey link and spending a few minutes completing the anonymised survey? This will give us costing data to use when negotiating tariffs with medical schemes.

Rejections of Claims for Psychiatric Patients

The rejection and non-payment of claims for patients undergoing in-patient psychiatric treatment have become an urgent problem facing dietitians working in psychiatric hospitals. HDIG has engaged with Medscheme to try to resolve this problem. Preliminary communications and meetings have revealed that there is no formal policy to exclude or reject dietetic claims.

Therefore, a meeting has been scheduled for December 2018 to examine benefit design, benefit specifications and the claims processes governing dietetic care for patients with a primary psychiatric diagnosis. This is an opportunity to provide insight and education to Medscheme about the importance of various aspects of dietetic care of patients with severe mental illness, including the management of nutrition-related side-effects of psychiatric medications, the ongoing management of chronic diseases, management of body weight, and other aspects of malnutrition.

The meeting will also be a chance to understand the correct procedures and processes necessary for successful claims for dietetic services to this type of patient, and this information will be distributed via the HDIG newsletter of early 2019. WCA claims HDIG continues to represent the profession in the public hearings related to our exclusion from WCA claims, and the Amendment to the Compensation for Occupational Injuries and Diseases Bill.

Among other things, the objective of the amendment to the Act was to improve the benefits to injured employees and to improve enforcement and compliance. The Department of Labour is currently holding a national roadshow with various meetings to engage with stakeholders on this issue. HDIG will represent dietitians at the Gauteng meeting on 3 December 2018.

Prescribing Rights of Dietitians

The rights and limits on prescription practices for dietitians have become a difficulty in some private facilities. The legislation in place is Act 101 of 1965 (The Medicines and Related Substances Act), which has been amended several times. There appear to be some differences in the way individual pharmacists, hospital pharmacies or private hospital facilities interpret how this Act governs prescribing practices of dietitians in these clinical settings.

For example, some hospital pharmacy managers prefer that the dietitian does not prescribe directly on the Drug Chart because this includes scheduled substances which require doctors prescriptions and are part of legal records governing medicines and drugs. Rather the dietitian should order items on a separate order form for unscheduled and low schedule items, or simply record their orders on the Instructions section of the Prescription Chart.

This seems to be an individual pharmacy practice rather than a legal issue. However, it would be useful for the whole profession if this matter were properly clarified and a suitable legal framework put in place since dietitians are not formally recognised prescribers of medicines and related substances.

HDIG has developed an Interim Policy Document on Prescribing Rights for Dietitians. We have engaged with the HPCSA task team on this matter, and HDIG has now been invited to attend task team meetings to push this issue forward. There have been repeated delays on the side of HPCSA Professional Board in revising the Scope of Practice of dietitians into which this issue falls. HDIG newsletter Nov 2018

At present, the following are the prescribing rights of dietitians:

1. Unscheduled substances (Foods for special medical purposes)

This category includes oral and/or enteral sip feeds (oral nutrition supplements), enteral feeds or modular nutrition supplements. Dietitians may prescribe or order these without a doctor’s signature or co-signature.

2. Schedule 0 and 1 substances

Dietitians may prescribe or order these without a doctor’s signature or co-signature.

3. Schedule 2 substances (oral micronutrients, fatty acids, minerals etc)

Substances in these categories may be ordered (“prescribed”) by a dietitian since they do not require a prescription from a medical doctor. However, they must be sold, issued or dispensed via the pharmacy (hospital or otherwise) since the law requires that a sale record is kept of the patient’s identity and the amount of the schedule 2 substance dispensed.

4. Schedule 3 substances (IV micronutrients, amino acids and parenteral nutrition)

Dietitians are currently not authorised to prescribe these substances under any circumstances, although they contribute to the planning and monitoring of their use in routine clinical practice. At least a co-signature of a medical doctor should accompany a “prescription” of schedule 3 items. In this case, the signature or co-signature of the dietitian carries no legal weight.

PMB Nutrition Benefits

Since the publication of the new regulations governing PMB defined benefits for nutrition support for two large categories of patients during 2017 (GIT Cancers) and 2018 (Palliative Care), there has been an increase in successful claims for these benefits.

Nevertheless, there are still problems with patients and dietitians accessing these benefits, and a lack of consistent application of these benefits by medical schemes.

The most important mistake causing claim rejections by medical aids is the application of the incorrect ICD-10 code when submitting motivations for these benefits. Figure 1 below outlines the main primary code that should be included to trigger coverage under this benefit. Multiple secondary ICD-10 codes may be used in conjunction with these primary codes.

Decision tree for primary ICD-10 code for nutrition benefits

Decision tree for primary ICD-10 code for nutrition benefits

NOTE: For patients needing palliative care, regardless of the diagnosis, the ICD-10 code Z51.5 must be the primary code, and all members of the clinical team should apply the code to the case.

NOTE: GIT cancer patients will need to be switched to a palliative care programme once they are no longer in active treatment. When this happens, the ICD-code also needs to be switched to Z51.5 in order to access the prescribed nutrition benefits for this stage of illness.

Discovery Advanced Illness Benefit

The Advanced Illness Benefit offered by Discovery is intended to extend the benefit coverage for patients with advanced disease, especially cancer. Dietetic services are not automatically included in this benefit. You have the best chance of success with AIB motivations if you orientate your motivation around symptom management (diarrhoea, constipation secondary to opiates, wound care, mucositis, nausea secondary to chemotherapy etc).

Payment From Incorrect Funding Pool

For PMB conditions, claims may not be paid out of the patient’s savings in the medical scheme package. Rather, PMB claims have to be paid out of scheme risk pool funds. It is apparent that for nutrition products and services (dietitian’s fees), schemes may be paying out of savings in the hope that this will go unnoticed or unchallenged. However, this is not allowed for PMB conditions and should be appealed immediately or taken to the complaints process.

 Ethical Billing Reminder

You are reminded to be familiar with the code of ethical practice and billing for the profession. You are entitled to bill for assessment, planning, implementation and monitoring of patients. Travel time and transport costs are not permitted to be claimed against medical schemes.

Precise recordkeeping is essential – every aspect of the dietetic care provided to a patient must be documented in the clinical notes since medical aids are at liberty to investigate unusual or suspicious billing patterns. Excellent record-keeping is an ethical duty to your patients, protects your practice and is an indication of professionalism.

Workshop offerings

Thank you to those dietitians who completed the online survey regarding proposed HDIG workshops. HDIG will offer a pilot workshop in Gauteng on ethical billing practices, successful motivations and other topics central to the work of the private practicing dietitian in hospital practice. Based on the response to this pilot workshop, further workshops will be offered in main city centres.

The first workshop will take place in the last week of January 2019 in Gauteng over lunchtime/early afternoon. For catering and venue purposes, please respond to info@hdig.co.za to register your intention to attend and receive further information on the details of this event.

THANK YOU!

Thank you to those who responded to the August newsletter with positive feedback and appreciation for the advocacy work HDIG attempts to do on behalf of our members, ADSA members and South African dietitians in general. It is very encouraging to receive this kind of comment as well as your interest in becoming more involved in HDIG.

Endnote

You received this newsletter via the ADSA PPD email contact list. HDIG is establishing a database of dietitians in hospital practice in order to keep everyone in the loop as to important matters affecting our practice, and build a critical mass of professional support to allow us to better represent the needs and interests of our profession. Please visit our website and register to receive HDIG communication and important newsflashes directly to your mailbox. You can also keep an eye on news and events via our web portal.

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