Medscheme update - Coronavirus (Covid-19) outbreak

We are all aware that on 31st December 2019, the World Health Organization (WHO) China country office reported a cluster of pneumonia cases in Wuhan City, Hubei Province. This was characterized by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), and has been confirmed as the causative virus of Coronavirus disease 2019 (Covid-19). Subsequently, as a result of the rapid worldwide spread of the virus the WHO has declared Covid-19 a Public Health Emergency of International Concern (PHEIC) with the global health community currently working to prevent or manage further spread and control the pandemic as much as possible.

President Cyril Ramaphosa addressed the nation on the 15th March 2020 announcing a range of measures to try and stem the Covid-19 epidemic. The South African National Institute for Communicable Diseases (NICD) and the National Department of Health (NDoH) has published several documents on how the outbreak should be managed and is available on their respective websites.

Medscheme acknowledges the confirmed cases up to date, as well as based on global trends that the risk of additional infections and confirmed cases is extremely probable and high risk. Therefore, proactive steps have been taken to ensure that all scheme members are covered in the event of Covid-19 infection.

The Council for Medical Schemes (CMS) has advised that Covid-19 will be funded as a Prescribed Minimum Benefit (PMB), however it is important to note that a viral infection like Covid-19 does not normally fall under the PMB conditions except as per legislation if the viral infection results in an emergency condition which then would fall within the PMB legislation.


Please note that only persons classified as a “Person Under Investigation (PUI)” need to be tested for possible infection.

Criteria for “Person Under Investigation (PUI)” classification as defined by the WHO and NICD:
Presentation with an acute respiratory illness with sudden onset of at least one of the following:

  • Cough
  • Sore throat
  • Shortness of breath
  • or Fever [≥ 38°C (measured) or history of fever (subjective)] irrespective of admission status


In the 14 days prior to onset of symptoms, met at least one of the following epidemiological criteria:

  • Were in close contact with a confirmed or probable case of Covid-19 infection


  • Had a history of international travel, mainly to areas with presumed ongoing community transmission of Covid-19 including but not limited to Mainland China, Italy, France, South Korea, Singapore, Japan, Iran, Hong Kong, Italy, Spain, United Kingdom, USA, Vietnam and others


  • Worked in, or attended a health care facility where patients with Covid-19 infections were being treated


  • Admitted with severe pneumonia of unknown aetiology.


a. Pathology tests

To date, only real-time nucleic acid amplification tests (NAATs, “PCR”) have been used to diagnose Covid-19 infection. Respiratory material (e.g. nasopharyngeal swab, sputum, endotracheal aspirate or bronchial alveolar lavage) is the preferred specimen type for future testing.
In South Africa, respiratory disease caused by a novel respiratory pathogen such as Covid-19 is a Class 1 notifiable medical condition, and should be reported immediately to the relevant district or provincial communicable disease coordinators once a case meeting the case definition above is identified. For this reason we are working closely with both the NICD and the NDOH in the testing of those suspected to have contracted the virus.
The private pathology laboratories have commenced testing, and they all need to comply with agreed protocols, as well as provide the NICD with both the numbers and results of those tested. The major laboratories confirmed that they will be testing and billing using the following code/s:

Lab - Test Code/s

Ampath - 3974
PathCare - 3974
Lancet - 4434
Vermaak & Partners - 3974

The above test codes are not specific to Covid-19 but can be billed for other viruses where the Polymerase Reaction Chain testing method is used. The diagnostic claims will be paid retrospectively using the description provided by the laboratories mentioning the specific test performed. We will be monitoring these to understand testing patterns for Covid-19.

b. Use of Radiology in diagnosis

There is some literature suggesting the use of Computer Tomography (CT) scans of the chest to assist in the diagnosis of Covid-19, in the setting of a negative test. Additionally there are concerns about the availability of test kits and sensitivity of the test.

The America College of Radiology (ACR) however is advising the following protocol for CT chest1:

  • CT should not be used to screen , or as a first-line test to diagnose Covid-19
  • CT should be used sparingly and reserved for hospitalized, symptomatic patients with specific clinical indications for CT. Appropriate infection control procedures should be followed before scanning subsequent patients.

We have engaged with the Radiology Society of South Africa (RSSA) who have advised that their recommendation to all radiologists is to apply the ACR guidelines and NOT advocate CT chest scans for diagnosis. As such the recommendation to Schemes is that diagnostic CT scans should NOT be funded for Covid-19, unless new information becomes available that requires this decision to be reviewed.

In our engagement with the radiologists we have also gained agreement that CT scans of the chest for the management of COVID-19 positive patients will be billed using the following tariff code:

30350: CT of the chest, complete high resolution study.

Currently CT chest under code 30350 will only be funded for confirmed COVID19 cases additionally CT scans should be used sparingly and reserved for hospitalized, symptomatic patients with specific clinical indications for CT.


a. Hospital access

We have engaged extensively with the hospital groups and have been given the assurance from Netcare, Life Healthcare and Mediclinic that all of their hospitals have the capability and are prepared to manage suspected and confirmed Covid-19 cases.

The isolation facilities vary between hospitals and their occupancy varies on a daily basis. If a patient requires specific treatment not available at the hospital of admission, they will transfer the patient to an alternative hospital that can provide this.

The hospital groups have dedicated Task Teams in place and are working closely with and are fully aligned with both the National Institute for Communicable Diseases (NICD) and the Department of Health. They are following the guidance provided by the NICD on who to test (only cases fulfilling the NICD case definition) and the process to follow regarding the testing required.

They request that members phone the hospital’s emergency department or their healthcare provider before coming in for a consultation if they are concerned that they may be infected or are infected with Covid-19. This will enable the hospital to take the appropriate precautionary measures to ensure that their staff and others at the facility are protected.

In addition Mediclinic has published a Risk Assessment Tool on its website as well as a Mediclinic COVID-19 hotline (0860 24 00 24) to support the public with enquiries. This will support the current NICD hotline that has been established.

b. Hospital billing

Medscheme is engaging with the hospital groups to discuss potential billing models for different levels of care of treatment and will share any relevant information once finalised

c. Pre-authorisations and Case Management

The predominant reasons for admission caused by a positive strain of Covid-19 are pneumonia (PMB), respiratory distress syndrome (PMB), bronchitis and lower respiratory tract infections. These conditions are currently high cost hospital admissions and all schemes have clearly defined protocols to manage these admissions and to manage the risks associated thereto. The pre-authorisation teams will continue to mitigate those risks by distinguishing between the normal clinical presentations of the conditions vs the novel Covid-19 strain related ones.

This information may not always be available at the point of the pre-authorisation request and to this end, the hospitals have been requested to provide Medscheme with the relevant codes upfront where possible. If the codes are provided upfront, this will trigger the process of focused case management:

  1. For confirmed Covid-19 requests (ICD10 code: U07.1), isolation will be approved and clinical updates will be requested every 3 days. High cost medication requests will be managed within the case management team.
  2. Where Covid-19 has not been confirmed or is still being investigated (ICD10 code: Z11.5), these requests will be managed as per current admission criteria via the clinical Appropriateness Evaluation Criteria process where applicable. The default length of stay of 1 overnight stay will be approved and case managed as per the current process. The case manager will request the blood results and/ or chest X-rays to confirm the diagnosis of pneumonia in line with the current process.
  3. For telemedicine consultation code 0130 can be used and will be subjected to Scheme specific rules.
  4. Discharge planning will commence as soon as the patient is clinically well and clearance has been received from the doctor.
  5. Requests for CT chest to diagnose Covid-19 will be declined unless new information becomes available that requires this decision to be reviewed.
  6. Whilst the list of designated hospitals from the various groups are awaited, the requests will be dealt with in line with the current process to approve the admission at the facility in the event of a confirmed Covid-19 case.

Medscheme is engaging with relevant stakeholders to continuously review funding protocols for the appropriate patient management in the event of a confirmed diagnosis. Should more information become available Medscheme will advise accordingly.

You can download the PDF here.

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