Billing and medical-aid claims for GP practices

General practice bills the bare four-digit code with its leading zero, and for a dispensing practice the medicine goes on the same claim under its NAPPI product code. Most of what goes wrong is not the consultation: it is the medicine line, the chronic condition behind it, or the patient on the membership the claim was meant for.

South African tariff codes come in more than one billed form, and which one applies depends on your discipline. Medical practitioners, GPs and specialists alike, bill the bare four-digit code — a GP bills 0190 as 0190, and a psychiatrist bills 2974 as 2974. Allied and paramedical disciplines bill their BHF discipline number followed by the procedure number. That procedure part is three digits for most disciplines and four for speech therapy and audiology, which is the exception people miss. General practice is discipline 14:

Discipline	BHF number	Billed code form
General practice	14	nnnn
Psychiatry	22	nnnn
Occupational therapy	66	66nnn
Podiatry	68	68nnn
Physiotherapy	72	72nnn
Counselling	81	81nnn
Audiology	82	82nnnn
Speech therapy	82	82nnnn
Dietetics	84	84nnn
Psychology	86	86nnn
Nursing and home-based care	88	88nnn
Social work	89	89nnn
Biokinetics	91	91nnn

This is invisible on a tariff schedule, because the schedule prints the short procedure number and leaves the form to you. For a medical practitioner the mistake runs the other way:following the allied convention and prefixing the discipline number produces a code the scheme has never heard of. It does not fail politely: codes come back unknown or priced at zero across the board rather than case by case. If that is what your rejections look like, check the form before you check anything else.

Each scheme’s own tariff schedule is the authority on its rates and codes. Where a scheme’s schedule disagrees with anything here, follow the schedule. Clinical technology is deliberately absent from the table above: its numbering is not consistent between schemes, so no single pattern would be correct.

Do GPs bill a 14-prefixed tariff code?

No. 14 identifies a general practice in its practice number, but GPs bill the bare four-digit code - a consultation printed as 0190 goes out as 0190. Prefixing the discipline number is an allied-health convention and produces a code the scheme does not recognise.

How does a dispensing GP bill medicine to a medical scheme?

Each medicine goes on the claim under the NAPPI code for that product and pack size, priced from the regulated single exit price plus a dispensing fee. Schemes may still pay less where the plan uses a formulary or a reference price, and the difference becomes the patient’s to pay.

Why was the medicine rejected when the consultation paid?

Most often because the chronic condition is not registered with the scheme, or the medicine is not on the plan’s formulary for it. The consultation and the medicine are assessed separately, so one line can pay while the other is refused.

Do general practice claims need an ICD-10 diagnosis code?

Yes. Every claim to a South African medical scheme needs a valid ICD-10 code, coded to the most specific level the record supports. For an injury the scheme also expects an external-cause code, and that cause code has to be a billable five-character code rather than a category heading.

What does billing software cost for a GP practice?

On NetPractice it is R9.50 per claim with the first 10 claims each month free, and no monthly fee or contract. A practice submitting 200 claims a month pays R1,805.