Accident
&
Medical
Agreement
Operational Guidelines
August 2011
This is a living document and will be updated as required
Accident & Medical – Operational Guidelines
Contents
Introduction ............................................................................................. 1
Service philosophy ................................................................................. 1
Enquiries .............................................................................................. 1
Accident and Medical Clinic Standard: NZS 8151 ...................................... 1
Providing accident and medical services .................................................. 1
What do A&M services involve? ............................................................... 1
Service documentation ........................................................................... 2
Client eligibility ........................................................................................ 2
Claiming for consultations and treatment ................................................ 3
Consultation Levels A to E ...................................................................... 3
Referral back to primary care provider ..................................................... 4
Claiming for more than one procedure at the same consultation .................. 5
Clients seen more than once on the same day ........................................... 5
Pharmaceuticals .................................................................................... 5
Consumables ........................................................................................ 6
Payments and invoicing ........................................................................... 6
Billing ACC for treatment provided ........................................................... 6
Co-payments ........................................................................................ 6
Medical conditions ................................................................................. 6
Invoicing under regulations ..................................................................... 7
Medical Fees Processing (MFP) centres ..................................................... 7
Monitoring ................................................................................................ 7
APPENDICES ............................................................................................ 8
Appendix 1: Table 1 - Consultation descriptions ........................................... 8
Appendix 2: Guidelines for claiming under consultation levels ...................... 11
Accident & Medical – Operational Guidelines
Introduction
The following information is designed to help you interpret the Accident and
Medical (A&M) Clinic’s Interim Agreement. This is a living document. Updated
versions will be made available as the need arises.
Service philosophy
The purpose of this service is to provide urgent treatment to clients with minor
injuries to promote rapid healing, rehabilitation and early return to work or
normal daily living activities.
A&M services are provided for the urgent treatment of acute injuries. Follow-up
treatment may be provided for a period of no more than eight weeks from the
time of the initial presentation to the A&M Clinic (“Clinic”). Following the acute
period of eight weeks the client must be referred back to the primary care
provider for ongoing treatment or managed by the Clinic under Regulations.
Enquiries
The following people can be contacted for any questions about the contracting
process:

Provider Helpline: ph 0800 222 070 or email providerhelp@acc.co.nz.

Provider Relationship Manager for your region: contact the Provider Helpline
to obtain contact details

Contracts Administrator and Health Procurement Facilitator: ph 0800 400 503
or email health.procurement@acc.co.nz.
Accident and Medical Clinic Standard: NZS 8151
ACC requires suppliers’ clinics to be accredited against the Accident and Medical
Clinic Standard NZS 8151. The A&M clinic has been successfully audited, and
must maintain compliance with, this standard.
Providing accident and medical services
What do A&M services involve?
Services provided under this agreement include different levels of consultation.
The levels are time-based. In addition to a consultation, the service provider may
carry out one or more of the procedures outlined in Part 1 Table 2 of the Accident
and Medical Service Schedule. In most circumstances, a Level B consultation will
be invoiced when providing a procedure. If a longer consultation is required, the
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clinical notes will support this.
Service documentation
Full and robust
Documentation from the service provider will show that the consultation and/or
recommended treatment meet best practice standards. Please make sure you
keep accurate and full clinical records. Clinical notes must meet the relevant
professional standards and the legislative requirements of the Accident
Compensation Act 2001 (AC Act). They must also be able to withstand the
scrutiny of peer review, audit (medical or financial) or a medico-legal challenge.
For guidance, refer to the ACC Treatment Provider Handbook.
Assessment details
ACC requires details of the assessment related to a consultation, ie not just the
final diagnosis but details of how the conclusion was reached, including whether
other diagnoses had been considered and ruled out. This is important to help ACC
clearly establish whether a condition has resulted from an injury rather than
being health-related.
The ACC45 form
Please ensure all parts of the ACC45 claim form are completed fully. All three
parts of the ‘accident description’ section in ‘Part B: Accident and Employer
Details’ should be filled in. This will not only help ACC assess whether the claim
meets ACC criteria, but also assists us to compile statistical data about injury
causes and tailor our injury prevention strategies.
ACC appreciates that the client is primarily responsible for filling in part B of the
form. However, they will not always know what information is relevant for ACC’s
purposes and in many cases would benefit from clinical guidance in completing
this section.
Client eligibility
A client is entitled to A&M services under this agreement if they:

have suffered a personal injury in terms of the Accident Compensation Act
2001 as defined in clause 6(1), for which a claim for cover has been accepted
or is likely to be accepted in the service provider’s experience, and

require urgent acute treatment and follow-up as necessary within the acute
8-week period defined above.
ACC will not pay the service provider for time spent with a person who does not
meet the criteria outlined above.
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Claiming for consultations and treatment
Consultation Levels A to E
Consultations are time-based. Procedures outlined in Part 1 Table 2 of the
Accident and Medical Service Schedule are included (without limitation) in the
specified consultation level.
The addition of a procedure(s) will reflect the time involved and the complexity of
the treatment given to the client during that particular consultation.
The applicable consultation level may be claimed and is payable for only one visit
per client per 24 hours, unless a second consultation visit is clinically justified and
supported by documentation. For more information please see: Clients seen more
than once on the same day (p5).
Level A consultations
The Level A consultation (nurse consultation of any duration) covers a variety of
treatment, without limitation, outlined in Appendix 1 Table 1.
It may also be claimed in conjunction with a procedure(s) as listed in Part 1
Table 2 of the Accident and Medical Service Schedule.
A Level A consultation may also be claimed if the accident-related condition was
not the primary reason for the presentation.
Example: the visit is a mixed Health and ACC related visit and will be paid if
the claim is accepted (refer Medical Conditions p6 of these Operational
Guidelines). This may be claimed on its own or in addition to a procedure(s),
where relevant.
Levels B, C and D consultations
Claims under consultation Levels B, C and D depend solely on the length of time
the medical practitioner spends with the patient. Any nurse input, irrespective of
duration, should not be used to justify the use of the higher levels of consultation
billing.
ACC expects that only a Level B consultation would usually be appropriate for an
unscheduled return visit, including the dressing of minor burns or abrasions (refer
to Appendix 1 Table 1). Clinical records will reflect the treatment required. If
there is delayed healing of a wound, the patient should be referred for a specialist
wound assessment. See Appendix 1 Table 1 for guidance of when to claim other
consultation levels relating to wound management.
A consultation on its own would be appropriate in certain situations where the
client requires a return to the clinic for treatment.
Example: a patient was initially seen for a fractured radius and initially A023
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(CONS B) and F360 was claimed. In this case a consultation without
procedures would be appropriate for the follow-up visit to apply a soft tissue
support bandage.
Claiming for consultations with more than one provider
If a patient enters the clinic and…
The provider(s) may claim…
the nurse independently performs any
services outlined in clause 5.2.1 of the
A&M Service Schedule
a Level A consultation may be claimed
for the time the nurse spent with the
patient. Clinical notes must reflect
appropriate nurse input.
the doctor then sees the patient and
provides a consultation
a consultation level appropriate to the
time the doctor spent with the patient
may be claimed along with any
appropriate procedures, irrespective of
nurse time.
the doctor and nurse see the patient at
the same time, and provide any of the
services outlined in clause 5.2.1 of the
A&M Services Schedule and any
relevant procedures
a consultation level solely dependent on
the length of time the doctor spends
with the patient may be claimed along
with any appropriate procedures
(irrespective of nurse time).
Level E consultations
A Level E consultation is a structured rehabilitation visit. Clinical records should
reflect the rationale for a Level E consultation and the outcome, including the
agreed rehabilitation plan. Only registered medical practitioners and nurses
providing A&M services under this contract may invoice ACC for a Level E
consultation. Other health professionals, eg physiotherapists, participating in the
structured rehabilitation visit will invoice ACC under Regulations or another
relevant contract.
There may be an exception, eg in the case of a more serious injury, that more
than one Level E Consultation is required. Documentation will reflect this need.
Follow-up consultations
Clinics may book a scheduled follow-up appointment for clients who need to
return to the clinic for subsequent treatment during the acute period. A Level A
(or triage) consultation cannot be charged for clients booked in for a scheduled
follow-up appointment. The intention of this service item is to allow clinics to
manage workflow. A follow-up visit does not require treatment by a medical
practitioner if the treatment may be appropriately provided by a registered nurse.
Clients who choose to drop in to the Clinic on an unscheduled basis for treatment
are not covered under the follow-up consultation code.
Referral back to primary care provider
Following the acute period, the client must be referred back to the primary care
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provider for any further follow-up and referrals. Comprehensive documentation of
the course of treatment and treatment plan will be provided to the primary care
provider by the supplier at the time of transfer of care. If the Clinic chooses to
follow the client after the acute period of 8 weeks, this must be invoiced under
Cost of Treatment Regulations.
Claiming for more than one procedure at the same
consultation
If two or more procedures are required on separate body sites during one
consultation, ACC will pay for:

the relevant consultation

plus any relevant procedures for an accepted claim.
If two or more procedures are required on a single body site during one
consultation, ACC will pay for:

the full consultation (usually Level B)

plus the full price of the most expensive procedure

and half the price for the second or subsequent procedure.
Clients seen more than once on the same day
ACC only pays for one consultation per day (within a 24-hour period) for a
particular claim. The exception is if a second consultation is clinically justified
and supported by documentation.
For example, ACC would consider paying for two consultations in one day when:

reassessing the client later in the day is clinically justifiable, the client’s
condition has deteriorated or a significant wound requires further dressing

the client is treated for one injury, leaves the surgery and has another
accident, in which case a second claim would be appropriate.
Your clinical notes may be requested if two consultations occurred in one day.
ACC is unlikely to pay for more than one consultation when the client is:

referred for an X-ray and returns for a consultation afterwards, regardless of
whether the same doctor or a second doctor assesses the client after the
X-ray

seen for multiple injuries or accidents in the visit/consultation.
Pharmaceuticals
Where pharmaceuticals are prescribed, ACC expects that subsidised
pharmaceuticals listed in the Pharmaceutical Schedule, and which meet its
subsidy criteria, will be prescribed. If non-subsidised pharmaceuticals need to be
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prescribed prior approval should be sought, and ACC’s funding contribution
confirmed, before writing the prescription. If it’s not possible to seek prior
approval before writing the prescription the client should be advised that ACC
may not reimburse prescription costs.
Consumables
Prices related to the consultation levels and procedures include materials,
consumable equipment, pharmaceutical items used during treatment and the
short-term loan of orthotics and equipment.
Exclusion
Moonboots, simple one use only orthotics and crutches are excluded from this
category as these are claimed under a GPE code.
Payments and invoicing
Billing ACC for treatment provided
The supplier will electronically invoice (eschedule) on the appropriate electronic
bulk billing schedule. For more information or any questions about electronic
invoicing please contact ACC’s ebusiness team on 0800 222 994 and select option
1, or email ebusinessinfo@acc.co.nz.
Co-payments
The service provider may charge clients a reasonable co-payment for services
provided under this agreement. However, the provider must inform the client of
the co-payment before beginning the consultation and/or procedure. ACC has no
liability to the service provider for the refusal or failure of any client to pay for
such a co-payment.
Medical conditions
If a client presents with both injury-related and accident-related conditions, ACC
will pay the applicable prices for the consultation and any procedure(s) required
to treat the client’s personal injury, only if the accident-related condition is the
primary reason the client sought the service provider’s services.
If a client receives treatment for an accident-related condition that was not the
primary reason for the client’s presentation, ACC will pay the Level A consultation
price set out in Part A, Clause 3, Table 1 of the A&M Service Schedule, and the
applicable price for any procedure(s) required to treat the client’s personal injury.
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Invoicing under regulations
Clients who do not meet the definition of “acute” for A&M Services can still be
treated at an A&M Clinic but ACC must be invoiced under Cost of Treatment
Regulations (with the exception of diagnostic films/reports).
Medical Fees Processing (MFP) centres
If you have any queries, please contact the Provider Helpline on 0800 222 070 or
email providerhelp@acc.co.nz.
Northern Processing Centre - Auckland:
The geographical area covered by the Northern Processing Centre includes the
North Island (except for the areas of the North Island covered by Dunedin
Processing Centre).
Postal address:
PO Box 90-341
Auckland Mail Centre
Auckland.
Elective Services Centre - Dunedin:
The geographical area covered by the Elective Services Centre covers all of the
South Island and includes the North Island from Taranaki across to the Hawkes
Bay, and below Taupo.
Postal address:
PO Box 408
Dunedin.
Monitoring
The purpose is to monitor progress and quality of service delivery under this
Agreement against expected performance, by comparison with peers.
Supplier invoicing patterns are regularly monitored by ACC. As part of the
monitoring process individual practice profiles (or invoicing patterns) are
reviewed. Suppliers whose profiles do not fit within the normal invoicing patterns
of their peers are contacted and asked for feedback on why their practice
patterns fall outside the normal parameters. This feedback is considered when
determining whether further investigation is necessary.
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APPENDICES
Appendix 1: Table 1 - Consultation descriptions
Level
A
Description
Nurse consultation
of any duration
Other Procedures
First consultations
 Assess and plan treatment and document accident
details, and
 Clean and dress simple wounds, eg superficial lacerations
smaller than 2cm, small single abrasions, single
contusions, with application of adhesive sutures,
elastoplasts or simple dressings
 Syringe ear to remove non embedded foreign body
 Simple removal of foreign body from eye (other than
embedded), nose, mouth, skin or subcutaneous tissue
 Irrigate eye or wound
 Administer tetanus toxoid, antibiotic injection
 Provide simple advice about rehabilitation process.
Unscheduled return consultations
 Re-application of simple splint to dislocated or fractured
digit
 Dressing change
 Removal of sutures
 Follow-up check of simple abrasions or lacerations or
sprains
 Check nasal packing
 Irrigate eye
 Administer tetanus toxoid, antibiotic injection
 Provide simple advice about rehabilitation process.
B
GP consultation expected range of
GP involvement of
5-20 minutes, plus
any nurse time
 Removal of sutures
 Removal of non-embedded foreign body from eye,
mouth, auditory canal or other site (excluding rectum or
vagina), without incision
 Dressing of minor single burns or abrasions
 Perform plaster checks
 Removal of casts
 Aspiration or incision, without use of infiltrated
anaesthetic, of small abscess or haematoma (including
dressing)
 Application of simple splint to dislocated or fractured digit
 Removal or debridement of nail or nails without
anaesthetic (without fracture)
 Removal of packing of nose, or packed abscess or
haematoma.
C
Extended GP
consultation expected range of
 Dressing of extensive burns, or multiple burns (not
including fractures)
 Removal of embedded or impacted foreign body from
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GP involvement of
21-40 minutes,
plus any nurse
time







cornea or conjunctiva, or from auditory canal, or nasal
passages, from skin or subcutaneous tissue with incision
Drainage of abscess or haematoma with incision (with or
without infiltration of local anaesthetic agent)
Application of splint (other than splinting of dislocated or
fractured digit) unless specified elsewhere
Insertion of IV line and administration of intravenous
antibiotics, or electrolytes
Closed reduction of fracture of phalanx (proximal, middle
or distal) of digit
Nail, simple removal of
Nail, removal of or wedge resection- requiring the use of
digital anaesthesia
Closed reduction of dislocated patella (plaster cast not
required)
 Closed reduction of fracture of metatarsus (not requiring
cast)
 Closed reduction of fracture of toe (great or otherwise)
 Closed reduction of fracture of nasal bones
 Removal of foreign body from rectum or vagina
 Reduction of dislocated shoulder without sedation
 Application of pressure dressing
 Injection of steroid into joint, tendon, bursa, or other
subcutaneous tissue or space
 Repositioning and splinting of displaced tooth
 Re-implantation of tooth
 Sedative dressing (or anaesthetic) for emergency dental
treatment.
D
Extended and
complex GP
consultation expected range of
GP involvement of
more than 40
minutes, plus any
nurse time
 Multiple fractures or multiple lacerations (or mixture of
both), including abrasions and contusions
 Reduction of dislocated shoulder without sedation
 Immobilisation of fractured patella
 Closed reduction of dislocation of talus
 Application of pressure trousers
 Performing crico-thyrostomy (including any associated
care such as resuscitation, monitoring, and patient
transfer).
Follow-up visit
 Follow-up visits are performed following the initial visit
 Follow-up visits are booked, pre-scheduled visits and do
not require triage
 Clients who are NOT scheduled in advance, or choose to
drop in for return treatments, are not covered under the
follow-up visit code
 No other consultation, including consultation Level A,
may be invoiced with a follow-up visit.
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E
GP/multidisciplinary
consultation structured
rehabilitation plan
visit
 Review of the injury, confirmation of the diagnosis
 May involve other health professionals
 The multidisciplinary consultation may occur for those
clients that have suffered a personal injury when a
detailed rehabilitation plan is required to assist in their
recovery
 The rehabilitation plan will include functional outcomes
with realistic timeframes
 As a result of the Level E consultation, the client may be
referred to other treatment
 The rehabilitation plan will be developed in conjunction
with the client and will be agreed by both parties
 Clinical notes will reflect the reason for this consultation
and agreed plan.
Note:
The price payable for other procedures and related consumables is included in the
consultation price.
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Appendix 2: Guidelines for claiming under consultation
levels
The following are examples of what to claim and at what level of consultation.

Ankle injuries which require an X-ray (ie that satisfy Ottawa Ankle
Guidelines) at the time of the initial consultation for diagnosis and
management

Knee injuries which require an X-ray (ie that satisfy Ottawa Knee
Guidelines) at the time of the initial consultation for diagnosis and
management

Shoulder injuries such as AC joint sprains, subluxations, spontaneous
dislocation and relocation injuries, rotator cuff tears and sprains which
require an X-ray at the time of the initial consultation for diagnosis and
management

Significant sprains and soft tissue injuries of limbs which require an
X-ray to rule out a fracture at the time of the initial consultation and to assist
with the diagnosis and management.
A Level C consultation would realistically reflect the time for the two consultations
required to assess, investigate, process, diagnose, treat, discuss, educate, and
refer where necessary, to obtain the appropriate clinical management and
outcome for the patient.
Achilles rupture
Achilles tendon rupture non-operative G721.

This is for the application of a full below-knee cast for an Achilles tendon
rupture. If the decision to operate is made and the operation happens quickly
then a full below-knee cast might not be applied for the pre-operative period,
but only when that period is short. In this situation G721 would not be
appropriate. However, if there are delays in getting to surgery then a cast
would be applied and therefore a G721 could be claimed.
Other

Complexity of the services provided: The use of a consultation level as
well as a procedure(s) will reflect the time involved and complexity in that
particular situation.

Analgesia and/or sedation: Some procedures (FO15 and F018) indicate the
requirement to “use of IV or IM sedation and analgesia”. In these situations
the clinician would make a clinical judgement and determine whether or not
sedation and/or analgesia is required. It would be reasonable to claim for
one of these procedures if one or both interventions (sedation or analgesia)
are used. Clinical notes would reflect the intervention performed.
Note:
A consultation Level C or D may be claimed in the situation where a shoulder
is relocated without the use of sedation.
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