Private hospital
fee schedule and
guidelines
Effective date: 1 July 2015
Contents
How to use this booklet ------------------------------------------------------------------------------------------------------------------ 2
Same-day services in a stand-alone day surgery facility --------------------------------------------------------------------------- 3
Accommodation -------------------------------------------------------------------------------------------------------------------------- 3
Theatre fee bands ------------------------------------------------------------------------------------------------------------------------ 3
Psychiatric hospital services ------------------------------------------------------------------------------------------------------------- 3
Emergency admission of workers to a psychiatric facility ------------------------------------------------------------------------- 4
Inpatient services ------------------------------------------------------------------------------------------------------------------------ 4
Drug and alcohol programs - inpatient ----------------------------------------------------------------------------------------------- 4
Same-day services ---------------------------------------------------------------------------------------------------------------------- 4
Rehabilitation hospital services --------------------------------------------------------------------------------------------------------- 5
Rehabilitation orthopaedic program for inpatients ---------------------------------------------------------------------------------5
Rehabilitation trauma program for inpatients ---------------------------------------------------------------------------------------5
Other hospital services-------------------------------------------------------------------------------------------------------------------- 6
Inpatient pain assessment/management -------------------------------------------------------------------------------------------- 6
Outpatient service – pain pumps ------------------------------------------------------------------------------------------------------ 6
Prostheses -------------------------------------------------------------------------------------------------------------------------------- 6
Interpretations ----------------------------------------------------------------------------------------------------------------------------- 7
Inpatient services – Diagnosis Related Groups version 7 -------------------------------------------------------------------------- 10
General information ---------------------------------------------------------------------------------------------------------------------- 39
Account and invoicing standards ---------------------------------------------------------------------------------------------------- 39
GST --------------------------------------------------------------------------------------------------------------------------------------- 39
Changes to provider details ----------------------------------------------------------------------------------------------------------- 39
Where payment is outstanding------------------------------------------------------------------------------------------------------- 39
Useful contacts ---------------------------------------------------------------------------------------------------------------------------- 39
Claims agents --------------------------------------------------------------------------------------------------------------------------- 40
ReturnToWorkSA EnABLE Unit ------------------------------------------------------------------------------------------------------ 40
Self-insured employers ---------------------------------------------------------------------------------------------------------------- 40
Allianz Australia SA Compulsory Third Party (CTP) ------------------------------------------------------------------------------- 40
ReturnToWorkSA - Private hospital fee schedule 2015-16
1
How to use this booklet
This booklet contains information on services and fees that apply to private hospitals that provide services to South
Australian workers who are managed under the Return to Work scheme.
This publication is based on the schedule published by the Minister for Industrial Relations in the South Australian
Government Gazette. Gazetted fees are the maximum fees chargeable, excluding GST. Where applicable, GST can be
applied over and above the gazetted fee.
All services and fees in this schedule are effective 1 July 2015.
Invoicing and service provision is actively monitored to ensure services are billed in accordance with this fee schedule and
that services are reasonable for the work injury and payable under the Return to Work Act 2014, (the Act).
This schedule contains the following:
1.
Stand-alone day surgery facility services
2.
Psychiatric services
3.
Rehabilitation services
4.
Other hospital services
5.
Interpretations
6.
In-patient services - Diagnosis related groups (DRGs)
7.
General information (including invoicing standards and useful contacts)
For copies of this document visit our website at www.rtwsa.com.
The gazetted version can be downloaded from the South Australian Government Gazette website at
www.governmentgazette.sa.gov.au
If you have any questions, please contact ReturnToWorkSA on 13 18 55.
ReturnToWorkSA - Private hospital fee schedule 2015-16
2
Same-day services in a stand-alone day surgery facility
Stand-alone day surgery facilities will be paid using the same-day services tables.
Accommodation
Item no.
Service description
Max fee (ex GST)
PR410
Band 1: including gastrointestinal endoscopy, some minor surgical and nonsurgical procedures not normally requiring anaesthetic.
$360.70
PR420
Band 2: including procedures other than Band 1 performed under local
anaesthetic with no sedation. Theatre time less than 1 hour.
$429.30
PR430
Band 3: including procedures other than Band 1 performed under a general or
regional anaesthesia or intravenous sedation. Theatre time less than 1 hour.
$501.60
PR440
Band 4: including procedures other than Band 1 performed under general or
regional anaesthesia or intravenous sedation. Theatre time 1 hour or more.
$531.80
Theatre fee bands
Item no.
Service description
Max fee (ex GST)
PRT1A
1A
$207.20
PRT01
1
$414.40
PRT02
2
$528.80
PRT03
3
$735.30
PRT04
4
$1,063.60
PRT05
5
$1,364.80
PRT06
6
$1,797.20
PRT07
7
$2,458.60
PRT08
8
$2,624.20
PRT9A
9A
$3,052.00
PRT09
9
$3,500.80
PRT10
10
$4,582.70
PRT11
11
$6,503.10
PRT12
12
$6,982.40
PRT13
13
$6,602.60
PRT50
Dental minor
$391.60
PRT55
Dental major
$706.50
Services in this section will be determined in accordance with the Group Accommodation and Theatre Banding Schedule
produced by the Commonwealth Department of Veterans’ Affairs, current at time of service.
Where more than one service is provided in a single theatre session, the theatre charge is –
a)
the service with the highest theatre charge plus
b) 50% of the service with the next highest theatre charge plus
c)
30% of each of the other services provided.
Psychiatric hospital services
ReturnToWorkSA - Private hospital fee schedule 2015-16
3
Emergency admission of workers to a psychiatric facility
The case manager must approve admission of a worker to a hospital when a medical practitioner believes that a worker
is at risk of harming themselves or others.
Where the psychiatric facility cannot obtain approval from the case manager (e.g. the incident occurs after business
hours) the facility must admit the person immediately. If this occurs the admitting psychiatric facility is required to advise
the case manager of the admission within two business days.
Private rooms are allocated on the basis of clinical need and the cost of such rooms is included in the charges set out
below. Where a worker requests a private room, ReturnToWorkSA will not be responsible for or accept any additional fee
or surcharge.
Inpatient services
Item no.
Service description
Max fee (ex GST)
PR800
Length of stay 1 or more days but not more than 14 days
$692.70 per day
PR803
15 or more days
$533.00 per day
PR822
Electro-convulsive therapy (ECT)
$296.60 per day
PR850
Private room allocated on the basis of clinical need
Extra $17.30 per day
Drug and alcohol programs - inpatient
Item no.
Service description
Max fee (ex GST)
PR990
Length of stay 1 or more days but not more than 10 days
$785.30 per day
PR991
11 or more days
$574.70 per day
Note: This program provides specialised treatment and care for patients with alcohol or drug dependencies (including
analgesics/narcotics/opiates and Benzodiazepine). The program is managed by a multi-disciplinary team including a
medical director and consultant psychiatrists. Where required, the program involves a medically controlled, safe
withdrawal of drugs or alcohol.
Same-day services
Item no.
Service description
Max fee (ex GST)
PRO81
Group session
PRO82
ECT day program
$492.30
PRO83
Half-day program
$252.10
PRO84
Day program
$398.90
PRO95
Outreach
$227.80
$94.50
Note: A day program is usually available to provide ongoing support and care to patients after discharge from treatment
as inpatients. It is managed by a multi-disciplinary team of health-care professionals, and is tailored to the individual
needs of the patient. It can include specialised therapy modules including cognitive behavioural therapy, relaxation,
assertiveness skills and anxiety management.
Outreach is treatment or care provided by the hospital to a non-admitted patient at a location outside the hospital
premises (being treatment or care provided as a direct substitute for treatment or care that would normally be provided
on the hospital premises).
ReturnToWorkSA - Private hospital fee schedule 2015-16
4
Please note, for billing purposes, the ‘O’ in item numbers for same-day services is an alphabetical letter not the number
zero.
Rehabilitation hospital services
Private rooms are allocated on the basis of clinical need and the cost of such rooms is included in the charges set out
below. Where a patient requests a private room, ReturnToWorkSA will not be responsible for or accept any additional
fee or surcharge.
Rehabilitation orthopaedic program for inpatients
Item no.
Service description
Max fee (ex GST)
PR600
Length of stay 1 or more days but not more than 16 days
$722.00 per day
PR605
17 or more days
$605.40 per day
Note: Orthopaedic programs involve referral and assessment by the rehabilitation coordinator of the program. They are
defined programs with intense service provision. Rapid improvement is expected and there are specific outcome goals.
The program includes physiotherapy, aquatic therapy, occupational therapy, case conferences and discharge planning.
Rehabilitation trauma program for inpatients
Item no.
Service description
PR610
Length of stay 1 or more days but not more than 20 days
PR615
21 or more days
Max fee (ex GST)
$860.90 per day
$777.30 per day
Note: Trauma programs involve referral and assessment by the rehabilitation coordinator of the program. They are
defined programs with intense service provision. Rapid improvement is expected and there are specific outcome goals.
The program includes physiotherapy, aquatic therapy, occupational therapy, speech therapy, case conferences and
discharge planning.
ReturnToWorkSA - Private hospital fee schedule 2015-16
5
Other hospital services
Inpatient pain assessment/management
Private rooms are allocated on the basis of clinical need and the cost of such rooms is included in the charges set out
below. Where a patient requests a private room, ReturnToWorkSA will not be responsible for or accept any
additional fee or surcharge.
Item no.
Service description
Max fee (ex GST)
PR700
Length of stay 1 or more days but not more than 7 days
$633.50 per day
PR705
8 or more days but not more than 14 days
$595.30 per day
PR710
15 or more days
$386.90 per day
Outpatient service – pain pumps
Item no.
Service description
PR720
Implanted infusion pump, refilling of reservoir, with a therapeutic agent or
agents, for infusion to the subarachnoid or epidural space, with or without
re-programming of a programmable pump, for the management of
chronic intractable pain for a non-admitted patient.
Max fee (ex GST)
$219.90
Prostheses
Item no.
Service description
CUR04
Prostheses will be paid in accordance with the Prostheses List produced by
the Department of Health and Ageing.
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max fee (ex GST)
DF
6
Interpretations
Acute patient means an admitted patient to an acute care facility (a) where a patient stays for the first 35 days of continuous hospitalisation, or
(b) where a patient who has been in continuous hospital care for more than 35 days where an Acute Care Certificate
(Form 918 from the Commonwealth Department of Health and Aged Care), or an equivalent form devised by the
hospital, has been completed and signed by a medical practitioner indicating the patient is to remain as an acute
care patient for a specified period.
Admission means the formal administrative process of a private hospital or day surgery facility by which the hospital or
facility commences the provision of treatment, care, accommodation and other services to a patient.
Admitted in relation to a patient in a private hospital or day surgery facility, means that the patient has undergone the
formal admission process of the hospital or facility and has not been discharged.
AR-DRG means Australian Refined Diagnosis Related Group and is referred to as DRG in this schedule.
AR-DRG reference numbers, descriptions and abbreviations. For the purposes of this Schedule –
(a) AR-DRG reference numbers or descriptions are as set out in the Manual and
(b) Terms and abbreviations used in AR-DRG descriptions have the meanings given by the Manual.
Criteria for admission
For the purposes of this schedule, a patient qualifies for admission to a private hospital or day surgery facility if he or she
satisfies one of the following criteria:
(a) The patient is to receive Day Only Band 1, 2, 3 and 4 services (excluding uncertified Type C professional attention
procedures) as specified in the Day Only Procedures Manual.
(b) The patient is to receive a Type C professional attention procedure as specified in the Day Only Procedures Manual
and there is an accompanying certification by a medical practitioner that an admission is necessary on the grounds
of the medical condition of the patient or other special circumstances relating to the patient.
(c) The patient, following a clinical decision, is expected to require overnight treatment for a minimum of one night.
(d) The patient is to receive a Type B professional attention procedure as specified in the Day Only Procedures Manual
and there is an accompanying certification by a medical practitioner that an overnight admission is necessary on the
grounds of the medical condition of the patient or other special circumstances relating to the patient.
Day means a calendar day.
Day Only Procedures Manual means the Day Only Procedures Manual published by the Commonwealth Department of
Health and Aged Care, as in force at time of service.
Day surgery facility means a facility (other than a private hospital or facility of a private hospital) designed for the
provision of medical, surgical or related treatment or care on a same day basis that is declared by ReturnToWorkSA by
notice in the Gazette to be a day surgery facility for the purposes of this schedule.
Discharge means the formal administrative process of a private hospital or day surgery facility by which the hospital or
facility ceases the provision of treatment, care, accommodation and other services to a patient.
Discharged in relation to a person who has been a patient in a private hospital or day surgery facility, means that the
person has undergone the formal discharge process of the hospital or facility.
Episodes of care, for the purposes of this schedule, includes (where applicable) the cost of the following:
(a) accommodation
(b) intensive care unit
(c) theatre
(d) common use theatre items
(e) pharmaceutical items directly related to the condition being treated
(f) television
(g) newspapers
ReturnToWorkSA - Private hospital fee schedule 2015-16
7
(h) local telephone calls
(i) all hotel services (e.g. meals etc.)
(j) consumable items.
Episodes of care, for the purposes of this schedule, do not include the following costs:
(a) the cost of prostheses
(b) the cost of substituted high cost single use items not commonly used in Australian clinical practice for delivery of the
service where the substitution for the usual item can be demonstrated to have been necessary for the treatment of
the patient
(c) the cost of allied health treatment (such as physiotherapy, dietetics, podiatry, psychology, social work, speech
pathology etc.)
(d) the cost of pharmaceutical items provided on discharge of a patient
(e) the cost of pharmaceutical items required for a patient for maintenance of an unrelated condition
(f) the cost of splints and braces required for the discharge of a patient
(g) transfer costs
(h) boarder fees.
Inlier patient means an admitted patient whose length of stay in a private hospital for a service identified, Inpatient
services – Diagnosis Related Groups falls within the range of the upper trim point days and the lower trim point days
(inclusive) specified in Inpatient services - Diagnosis Related Groups corresponding to that service.
Inpatient in relation to a private hospital means an admitted patient who, following a clinical decision, requires or is
expected to require overnight treatment for a minimum of one night.
Length of stay (LOS), in relation to an admitted patient in a private hospital, means the number of days between the day
of admission of the patient to the hospital and the day of discharge of the patient from the hospital –
(a) counting the day of admission as one day, and
(b) excluding the day of discharge (unless it is also the day of admission).
Long-stay outlier patient means an admitted patient whose length of stay in a private hospital for a service identified in
Inpatient services – Diagnosis Related Groups, is greater than the upper trim point specified in column 4 of the table
corresponding to that service.
Long-stay outlier fee calculation
The upper trim point is set as the average LOS x 2. The outlier payments will commence the next day after the upper trim
point.
Fee for long-stay outlier patients is calculated as follows:
Maximum fee = (schedule fee) + (rate per day x (LOS – upper trim point))
Manual means the Australian Refined Diagnosis Related Groups, Version 7.0 (as amended), produced by the
Commonwealth Department of Health and Aged Care).
Same day in relation to a service, means a service that is provided on a single calendar day.
Same day patients means an admitted patient to a registered stand-alone day surgery facility only.
Fees for same day patients in a registered day facility are calculated as follows:
Maximum fee = Theatre fee plus same day accommodation fee as per this Schedule.
Short-stay outlier patient means an admitted patient whose length of stay in a private hospital for a service identified in
Inpatient services – Diagnosis Related Groups for which the lower trim point days specified in column 5 of the table
corresponding to that service, is less than that lower trim point but greater than zero.
Short-stay outlier fee calculation
The lower trim point is set as the average LOS divided by 3.
ReturnToWorkSA - Private hospital fee schedule 2015-16
8
The accommodation payment will be paid at the per day rate for each occupied bed per day when the LOS is less than
the lower trim point. ICU fees are included in the per day accommodation rate.
Fee for short-stay outlier patients is calculated as follows:
Maximum fee = Rate per day x LOS
Transfers
Where the patient is transferred from the private hospital to another hospital, the maximum charge for the service
provided by the transferring hospital is 80% of the maximum charge. The receiving hospital subject to admission criteria
will be paid as a new episode of care.
Transitional arrangements – where treatment commenced before 1 July 2015 and continues beyond that date, the
discharge date is used for billing purposes.
ReturnToWorkSA - Private hospital fee schedule 2015-16
9
Inpatient services – Diagnosis Related Groups version 7
Private rooms are allocated on the basis of clinical need and the cost of such rooms is included in the charges set out
below. Where a patient requests a private room, ReturnToWorkSA will not be responsible for or accept any additional
fee or surcharge.
Registered hospitals will be paid on a DRG basis – please refer to Interpretation section.
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
801A
OR procedures unrelated to principal
diagnosis w catastrophic cc
17,652.00
35
7
746.00
801B
OR procedures unrelated to principal
diagnosis w severe or moderate cc
9,701.00
20
3
863.00
801C
OR procedures unrelated to principal
diagnosis w/o cc
4,016.00
5
0
1,100.00
960Z
Ungroupable
724.00
35
16
13.00
961Z
Unacceptable principal diagnosis
434.00
4
0
434.00
A06A
Tracheostomy w ventilation >=96hrs w
catastrophic cc
116,489.00
35
18
1,100.00
A06B
Ventilation >=96hrs and OR proc (w/o
tracheostomy or w/o cat cc)
56,581.00
35
11
1,100.00
A06C
Tracheostomy w/o ventilation >=96hrs, or
ventilation >=96hrs w/o OR proc
42,588.00
35
7
1,100.00
A08A
Autologous bone marrow transplant w
catastrophic cc
15,716.00
35
8
624.00
A08B
Autologous bone marrow transplant w/o
catastrophic cc
14,535.00
25
4
1,100.00
A11B
Insertion of implantable spinal infusion device
w/o catastrophic cc
4,798.00
13
2
711.00
A12Z
Insertion of neurostimulator device
5,030.00
7
1
1,100.00
B01A
Ventricular shunt revision w catastrophic or
severe cc
7,620.00
17
3
843.00
B01B
Ventricular shunt revision w/o catastrophic or
severe cc
4,989.00
9
1
996.00
B02A
Cranial procs w cerebral haemorrhage w cat cc
37,586.00
35
8
1,100.00
B02B
Cranial procs w/o cerebral haem w cat cc or (w
cerebral haem w sev cc)
26,082.00
35
6
1,100.00
B02C
Cranial procs w/o cerebral haem w sev cc or
w/o cat/sev cc
13,884.00
15
2
1,100.00
B03A
Spinal procedures w catastrophic or severe cc
13,049.00
23
4
997.00
B03B
Spinal procedures w/o catastrophic or severe
cc
6,827.00
7
1
1,100.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
10
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
B04A
Extracranial vascular procedures w
catastrophic cc
B04B
14,748.00
21
3
1,100.00
Extracranial vascular procedures w/o
catastrophic cc
6,844.00
8
1
1,100.00
B05Z
Carpal tunnel release
1,214.00
4
0
815.00
B06A
Procs for cerebral palsy, muscular dystrophy,
neuropathy w cat or sev cc
11,037.00
27
4
771.00
B06B
Procs for cerebral palsy, muscular dystrophy,
neuropathy w/o cat or sev cc
2,509.00
4
0
1,100.00
B06C
Procs for cerebral palsy, muscular dystrophy,
neuropathy, sameday
1,418.00
1
1
NA
B07A
Cranial or peripheral nerve and other nervous
system procedures w cc
10,030.00
26
4
676.00
B07B
Cranial or peripheral nerve and other nervous
system procedures w/o cc
2,260.00
4
0
961.00
B41Z
Telemetric EEG monitoring
2,104.00
8
1
596.00
B60A
Acute paraplegia/quadriplegia w or w/o OR
procs w catastrophic cc
22,619.00
35
15
518.00
B60B
Acute paraplegia/quadriplegia w or w/o OR
procs w/o catastrophic cc
499.00
11
2
96.00
B61A
Spinal cord conditions w or w/o OR
procedures w catastrophic or severe cc
13,311.00
34
6
728.00
B61B
Spinal cord conditions w or w/o OR
procedures w/o catastrophic or severe cc
6,665.00
9
1
1,100.00
B63Z
Dementia and other chronic disturbances of
cerebral function
6,443.00
21
3
621.00
B64A
Delirium w catastrophic cc
9,105.00
31
5
596.00
B64B
Delirium w/o catastrophic cc
5,425.00
16
3
678.00
B65A
Cerebral palsy
3,002.00
17
3
371.00
B65B
Cerebral palsy, sameday
449.00
1
1
NA
B66A
Nervous system neoplasms w radiotherapy
9,642.00
35
6
535.00
B66B
Nervous system neoplasms w/o radiotherapy
w catastrophic or severe cc
8,560.00
27
4
642.00
B66C
Nervous system neoplasms w/o radiotherapy
w/o catastrophic or severe cc
4,364.00
12
2
750.00
B67A
Degenerative nervous system disorders w
catastrophic or severe cc
8,171.00
29
5
573.00
B67B
Degenerative nervous system disorders w/o
catastrophic or severe cc
4,121.00
12
2
718.00
B67C
Degenerative nervous system disorders,
sameday
309.00
1
1
NA
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
11
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
B68A
Multiple sclerosis and cerebellar ataxia w cc
4,909.00
19
3
538.00
B68B
Multiple sclerosis and cerebellar ataxia w/o cc
661.00
4
0
549.00
B69A
TIA and precerebral occlusion w catastrophic
or severe cc
5,196.00
17
3
639.00
B69B
TIA and precerebral occlusion w/o
catastrophic or severe cc
2,430.00
7
1
727.00
B70A
Stroke & other cerebrovascular disorders w
catastrophic cc
11,456.00
35
6
666.00
B70B
Stroke & other cerebrovascular disorders w
severe cc
7,799.00
20
3
808.00
B70C
Stroke & other cerebrovascular disorders w/o
catastrophic or severe cc
4,597.00
12
2
820.00
B70D
Stroke & other cerebrovascular disorders,
died/trans acute facility <5 days
1,713.00
5
0
808.00
B71A
Cranial and peripheral nerve disorders w cc
6,530.00
20
3
672.00
B71B
Cranial and peripheral nerve disorders w/o cc
3,378.00
11
2
638.00
B71C
Cranial and peripheral nerve disorders,
sameday
546.00
1
1
NA
B72A
Nervous system infection except viral
meningitis w cat or sev cc
5,691.00
22
4
523.00
B72B
Nervous system infection except viral
meningitis w/o cat or sev cc
3,751.00
11
2
690.00
B73Z
Viral meningitis
1,818.00
8
1
511.00
B74A
Nontraumatic stupor and coma w
catastrophic or severe cc
4,260.00
29
5
295.00
B74B
Nontraumatic stupor and coma w/o
catastrophic or severe cc
1,593.00
5
0
789.00
B75Z
Febrile convulsions
246.00
4
0
177.00
B76A
Seizures w catastrophic or severe cc
5,066.00
20
3
523.00
B76B
Seizures w/o catastrophic or severe cc
2,021.00
7
1
589.00
B76C
Seizures, sameday
245.00
1
1
NA
B77Z
Headache
1,884.00
6
1
607.00
B78A
Intracranial injuries w catastrophic or severe
cc
8,415.00
31
5
558.00
B78B
Intracranial injuries w/o catastrophic or severe
cc
4,444.00
13
2
719.00
B78C
Intracranial injuries, died or transferred to
acute facility <5 days
1,834.00
4
0
1,079.00
B79B
Skull fractures w/o catastrophic or severe cc
1,820.00
7
1
587.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
12
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
B80A
Other head injuries w catastrophic or severe
cc
4,221.00
17
3
497.00
B80B
Other head injuries w/o catastrophic or severe
cc
579.00
4
0
358.00
B81A
Other disorders of the nervous system w
catastrophic or severe cc
6,252.00
21
3
599.00
B81B
Other disorders of the nervous system w/o
catastrophic or severe cc
2,507.00
8
1
634.00
B82A
Chronic and unspec para/quadriplegia w or
w/o OR proc w skin grft/flap repair
14,818.00
35
12
358.00
B82B
Chronic and unspec para/quadriplegia w or
w/o OR proc w cat cc
21,821.00
35
10
724.00
B82C
Chronic and unspec para/quadriplegia w or
w/o OR proc w/o cat cc
4,270.00
12
2
683.00
C01Z
Procedures for penetrating eye injury
1,527.00
4
0
573.00
C02Z
Enucleations and orbital procedures
2,735.00
4
0
1,100.00
C03Z
Retinal procedures
1,548.00
4
0
1,100.00
C04Z
Major corneal, scleral and conjunctival
procedures
1,557.00
4
0
938.00
C05Z
Dacryocystorhinostomy
2,106.00
4
0
1,100.00
C10Z
Strabismus procedures
1,216.00
4
0
669.00
C11Z
Eyelid procedures
1,497.00
4
0
829.00
C12Z
Other corneal, scleral and conjunctival
procedures
1,119.00
4
0
689.00
C13Z
Lacrimal procedures
813.00
4
0
516.00
C14Z
Other eye procedures
1,004.00
4
0
579.00
C15Z
Glaucoma and complex cataract procedures
1,418.00
4
0
811.00
C16Z
Lens procedures
1,690.00
4
0
1,100.00
C60A
Acute and major eye infections w cc
5,411.00
23
4
485.00
C60B
Acute and major eye infections w/o cc
3,428.00
11
2
636.00
C61A
Neurological and vascular disorders of the eye
w cc
2,703.00
10
2
595.00
C61B
Neurological and vascular disorders of the eye
w/o cc
1,609.00
5
0
653.00
C62A
Hyphaema and medically managed trauma to
the eye, w cc
4,184.00
14
2
609.00
C62B
Hyphaema and medically managed trauma to
the eye w/o cc
1,421.00
5
0
574.00
C63A
Other disorders of the eye w cc
1,858.00
6
0
621.00
C63B
Other disorders of the eye w/o cc
775.00
4
0
401.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
13
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
D01Z
Cochlear implant
4,125.00
4
0
1,100.00
D02A
Head and neck procedures w microvascular
tissue transfer or w cat/sev cc
10,916.00
17
3
1,100.00
D02B
Head and neck procedures w malignancy or w
mod cc
4,501.00
6
0
1,100.00
D02C
Head and neck procedures w/o malignancy
w/o cc
3,337.00
4
0
1,100.00
D03Z
Surgical repair for cleft lip and palate
disorders
2,084.00
4
0
799.00
D04Z
Maxillo surgery
3,446.00
4
0
1,100.00
D05Z
Parotid gland procedures
4,399.00
5
0
1,100.00
D06Z
Sinus and complex middle ear procedures
2,529.00
4
0
1,100.00
D10Z
Nasal procedures
2,067.00
4
0
1,100.00
D11Z
Tonsillectomy and/or adenoidectomy
1,488.00
4
0
1,100.00
D12A
Other ear, nose, mouth and throat procedures
w cc
3,106.00
7
1
795.00
D12B
Other ear, nose, mouth and throat procedures
w/o cc
1,735.00
4
0
1,006.00
D13Z
Myringotomy w tube insertion
964.00
4
0
657.00
D14A
Mouth and salivary gland procedures w cc
1,742.00
4
0
843.00
D14B
Mouth and salivary gland procedures w/o cc
1,416.00
4
0
945.00
D15Z
Mastoid procedures
3,195.00
4
0
1,100.00
D40Z
Dental extractions and restorations
944.00
4
0
792.00
D60A
Ear, nose, mouth and throat malignancy w
catastrophic or severe cc
9,243.00
31
5
612.00
D60B
Ear, nose, mouth and throat malignancy w/o
catastrophic or severe cc
3,075.00
8
1
763.00
D60C
Ear, nose, mouth and throat malignancy,
sameday
974.00
1
1
NA
D61A
Dysequilibrium w cc
3,603.00
12
2
611.00
D61B
Dysequilibrium w/o cc
2,349.00
7
1
716.00
D61C
Dysequilibrium, sameday
521.00
1
1
NA
D62A
Epistaxis
2,081.00
7
1
636.00
D62B
Epistaxis, sameday
852.00
1
1
NA
D63A
Otitis media and upper respiratory infections
w cc
3,160.00
11
2
579.00
D63B
Otitis media and upper respiratory infections
w/o cc
1,754.00
6
0
616.00
D63C
Otitis media and upper respiratory infections,
sameday
450.00
1
1
NA
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
14
Item no
Description
D64Z
Laryngotracheitis and epiglottitis
D65Z
Upper trim
point days
Lower trim
point days
389.00
4
0
288.00
Nasal trauma and deformity
1,115.00
4
0
587.00
D66A
Other ear, nose, mouth and throat disorders w
cc
2,986.00
9
1
651.00
D66B
Other ear, nose, mouth and throat disorders
w/o cc
930.00
4
0
740.00
D66C
Other ear, nose, mouth and throat disorders,
sameday
704.00
1
1
NA
D67A
Oral and dental disorders
2,408.00
9
1
568.00
D67B
Oral and dental disorders, sameday
738.00
1
1
NA
E01A
Major chest procedures w catastrophic cc
17,105.00
26
4
1,100.00
E01B
Major chest procedures w/o catastrophic cc
10,084.00
14
2
1,100.00
E02A
Other respiratory system OR procedures w
catastrophic cc
12,195.00
30
5
766.00
E02B
Other respiratory system OR procedures w
severe or moderate cc
4,984.00
9
1
1,050.00
E02C
Other respiratory system OR procedures w/o
cc
2,077.00
4
0
1,100.00
E40A
Respiratory system disorders w ventilator
support
18,029.00
32
5
1,100.00
E41A
Respiratory system disorders w non-invasive
ventilation w catastrophic cc
17,315.00
35
6
1,001.00
E41B
Respiratory system disorders w non-invasive
ventilation w/o catastrophic cc
6,324.00
20
3
634.00
E42A
Bronchoscopy w catastrophic cc
11,377.00
35
6
643.00
E42B
Bronchoscopy w/o catastrophic cc
5,086.00
14
2
721.00
E42C
Bronchoscopy, sameday
1,161.00
1
1
NA
E60A
Cystic fibrosis w catastrophic or severe cc
600.00
23
4
52.00
E60B
Cystic fibrosis w/o catastrophic or severe cc
1,443.00
14
2
209.00
E61A
Pulmonary embolism w catastrophic cc
8,117.00
26
4
628.00
E61B
Pulmonary embolism w/o catastrophic cc
4,447.00
13
2
726.00
E62A
Respiratory infections/inflammations w
catastrophic cc
8,688.00
26
4
689.00
E62B
Respiratory infections/inflammations w severe
or moderate cc
5,261.00
15
3
700.00
E62C
Respiratory infections/inflammations w/o cc
3,119.00
10
2
682.00
E63Z
Sleep apnoea
625.00
4
0
597.00
E64A
Pulmonary oedema and respiratory failure
6,655.00
18
3
748.00
E64B
Pulmonary oedema and respiratory failure,
died/trans acute facility <5 days
1,804.00
4
0
965.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max fee
(ex GST)
Max per day
rate (ex GST)
15
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
E65A
Chronic obstructive airways disease w
catastrophic cc
8,092.00
26
4
637.00
E65B
Chronic obstructive airways disease w/o
catastrophic cc
5,222.00
16
3
684.00
E66A
Major chest trauma w catastrophic cc
9,016.00
31
5
594.00
E66B
Major chest trauma w severe or moderate cc
5,990.00
18
3
689.00
E66C
Major chest trauma w/o cc
4,147.00
13
2
683.00
E67A
Respiratory signs and symptoms
3,718.00
11
2
664.00
E67B
Respiratory signs and symptoms, <2 days
1,409.00
4
0
1,004.00
E68A
Pneumothorax w catastrophic or severe cc
3,605.00
16
3
466.00
E68B
Pneumothorax w/o catastrophic or severe cc
2,113.00
6
1
704.00
E69A
Bronchitis and asthma w cc
4,515.00
14
2
649.00
E69B
Bronchitis and asthma w/o cc
1,668.00
6
0
583.00
E70A
Whooping cough and acute bronchiolitis w cc
1,421.00
9
1
324.00
E70B
Whooping cough and acute bronchiolitis w/o
cc
926.00
4
0
495.00
E71A
Respiratory neoplasms w catastrophic cc
8,096.00
27
4
602.00
E71B
Respiratory neoplasms w/o catastrophic cc
4,845.00
15
2
681.00
E71C
Respiratory neoplasms, sameday
569.00
1
1
NA
E73A
Pleural effusion w catastrophic cc
7,088.00
22
4
637.00
E73B
Pleural effusion w severe or moderate cc
3,867.00
12
2
661.00
E73C
Pleural effusion w/o cc
1,874.00
6
0
671.00
E74A
Interstitial lung disease w catastrophic cc
7,948.00
26
4
629.00
E74B
Interstitial lung disease w severe or moderate
cc
6,164.00
18
3
694.00
E74C
Interstitial lung disease w/o cc
3,491.00
11
2
669.00
E75A
Other respiratory system disorders w cc
5,361.00
17
3
654.00
E75B
Other respiratory system disorders w/o cc
2,494.00
8
1
667.00
F01A
Implantation or replacement of AICD, total
system w catastrophic cc
14,891.00
20
3
1,100.00
F01B
Implantation or replacement of AICD, total
system w/o catastrophic cc
8,404.00
5
0
1,100.00
F02Z
Other AICD procedures
7,980.00
7
1
1,100.00
F03A
Cardiac valve procs w CPB pump w invasive
cardiac inves w cat cc
34,460.00
35
7
1,100.00
F03B
Cardiac valve procs w CPB pump w invasive
cardiac inves w/o cat cc
23,526.00
23
4
1,100.00
F04A
Cardiac valve procs w CPB pump w/o invasive
cardiac inves w cat cc
27,079.00
27
4
1,100.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
16
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
F04B
Cardiac valve procs w CPB pump w/o invasive
cardiac inves w/o cat cc
21,842.00
19
3
1,100.00
F05A
Coronary bypass w invasive cardiac
investigation w catastrophic cc
32,124.00
34
6
1,100.00
F05B
Coronary bypass w invasive cardiac
investigation w/o catastrophic cc
25,357.00
25
4
1,100.00
F06A
Coronary bypass w/o invasive cardiac
investigation w catastrophic cc
25,853.00
25
4
1,100.00
F06B
Coronary bypass w/o invasive cardiac
investigation w/o catastrophic cc
21,724.00
19
3
1,100.00
F07A
Other cardiothoracic/vascular procedures w
CPB pump w catastrophic cc
20,719.00
27
4
1,100.00
F07B
Other cardiothoracic/vascular procedures w
CPB pump w/o catastrophic cc
16,875.00
16
3
1,100.00
F08A
Major reconstructive vascular procedures w/o
CPB pump w cat cc
21,130.00
29
5
1,100.00
F08B
Major reconstructive vascular procedures w/o
CPB pump w/o cat cc
11,283.00
12
2
1,100.00
F09A
Other cardiothoracic procs w/o CPB pump w
catastrophic cc
19,492.00
28
5
1,100.00
F09B
Other cardiothoracic procs w/o CPB pump w/o
catastrophic cc
10,044.00
8
1
1,100.00
F09C
Other cardiothoracic procs w/o CPB pump,
died/trans acute facility <5 days
5,402.00
4
0
0.00
F10A
Interventional coronary procedures admitted
for AMI w catastrophic cc
17,536.00
20
3
1,100.00
F10B
Interventional coronary procedures admitted
for AMI w/o catastrophic cc
11,333.00
8
1
1,100.00
F11A
Amputation, except upper limb and toe, for
circulatory disorders w cat cc
29,627.00
35
11
829.00
F11B
Amputation, except upper limb and toe, for
circulatory disorders w/o cat cc
12,061.00
33
5
693.00
F12A
Implantation or replacement of pacemaker,
total system w catastrophic cc
10,646.00
23
4
826.00
F12B
Implantation or replacement of pacemaker,
total system w/o catastrophic cc
5,223.00
6
0
1,100.00
F13A
Amputation, upper limb and toe, for
circulatory disorders w cat or sev cc
14,243.00
35
6
689.00
F13B
Amputation, upper limb and toe, for
circulatory disorders w/o cat or sev cc
7,752.00
15
2
922.00
F14A
Vascular procs, except major reconstruction,
w/o CPB pump w cat cc
14,187.00
22
4
1,100.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
17
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
F14B
Vascular procs, except major reconstruction,
w/o CPB pump w sev or mod cc
6,289.00
6
0
1,100.00
F14C
Vascular procs, except major reconstruction,
w/o CPB pump w/o cc
4,791.00
4
0
1,100.00
F15A
Interventional coronary procs, not adm for
AMI w stent implant w cat/sev cc
11,335.00
8
1
1,100.00
F15B
Interventional coronary procs, not adm for
AMI w stent implant w/o cat/sev cc
9,753.00
4
0
1,100.00
F16A
Interventional coronary procs, not adm for
AMI w/o stent implant w cc
10,766.00
10
2
1,100.00
F16B
Interventional coronary procs, not adm for
AMI w/o stent implant w/o cc
8,777.00
4
0
1,100.00
F17Z
Insertion or replacement of pacemaker
generator
2,775.00
4
0
1,100.00
F18A
Other pacemaker procedures w cc
9,064.00
16
3
993.00
F18B
Other pacemaker procedures w/o cc
5,412.00
5
0
1,100.00
F19A
Trans-vascular percutaneous cardiac
intervention, age >=80 or w cc
11,025.00
14
2
1,027.00
F19B
Trans-vascular percutaneous cardiac
intervention, age <80 w/o cc
5,137.00
4
0
1,100.00
F20Z
Vein ligation and stripping
2,711.00
4
0
1,100.00
F21A
Other circulatory system OR procedures w
catastrophic cc
17,148.00
35
9
627.00
F21B
Other circulatory system OR procedures w/o
catastrophic cc
6,214.00
13
2
876.00
F40A
Circulatory disorders w ventilator support
22,026.00
31
5
1,100.00
F40B
Circulatory disorders w ventilator support,
died/trans acute facility <5 days
5,731.00
5
0
1,100.00
F41A
Circulatory disorders, adm for AMI w invasive
cardiac inves w cat or sev cc
9,612.00
15
2
1,100.00
F41B
Circulatory disorders, adm for AMI w invasive
cardiac inves w/o cat or sev cc
6,042.00
7
1
1,100.00
F42A
Circulatory dsrds, not adm for AMI w invasive
cardiac inves w cat/sev cc
6,570.00
13
2
893.00
F42B
Circulatory dsrds, not adm for AMI w invasive
cardiac inves w/o cat/sev cc
4,586.00
4
0
1,100.00
F42C
Circulatory dsrds, not adm for AMI w invasive
cardiac inves, sameday
2,912.00
1
1
NA
F43Z
Circulatory disorders w non-invasive
ventilation
14,429.00
30
5
945.00
F60A
Circulatory dsrd, adm for AMI w/o invasive
cardiac inves
6,127.00
15
3
815.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
18
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
F60B
Circulatory dsrd, adm for AMI w/o invas card
inves, died/trans ac fac <5 days
2,163.00
4
0
1,100.00
F61A
Infective endocarditis w catastrophic cc
12,540.00
35
9
468.00
F61B
Infective endocarditis w/o catastrophic cc
7,715.00
28
5
547.00
F62A
Heart failure and shock w catastrophic cc
10,077.00
29
5
714.00
F62B
Heart failure and shock w/o catastrophic cc
5,514.00
15
2
747.00
F62C
Heart failure and shock, died or transferred to
acute facility <5 days
2,612.00
5
0
1,100.00
F63A
Venous thrombosis w catastrophic or severe
cc
5,767.00
17
3
693.00
F63B
Venous thrombosis w/o catastrophic or severe
cc
3,160.00
10
2
650.00
F64A
Skin ulcers in circulatory disorders w
catastrophic or severe cc
11,723.00
35
6
606.00
F64B
Skin ulcers in circulatory disorders w/o
catastrophic or severe cc
3,313.00
11
2
602.00
F65A
Peripheral vascular disorders w catastrophic
or severe cc
6,562.00
20
3
678.00
F65B
Peripheral vascular disorders w/o catastrophic
or severe cc
1,496.00
4
0
738.00
F66A
Coronary atherosclerosis w catastrophic or
severe cc
5,316.00
17
3
645.00
F66B
Coronary atherosclerosis w/o catastrophic or
severe cc
2,136.00
6
0
831.00
F67A
Hypertension w catastrophic or severe cc
4,464.00
16
3
569.00
F67B
Hypertension w/o catastrophic or severe cc
2,779.00
8
1
718.00
F68Z
Congenital heart disease
762.00
4
0
438.00
F69A
Valvular disorders w catastrophic or severe cc
5,714.00
17
3
692.00
F69B
Valvular disorders w/o catastrophic or severe
cc
1,509.00
4
0
713.00
F72A
Unstable angina w catastrophic or severe cc
5,556.00
15
2
775.00
F72B
Unstable angina w/o catastrophic or severe cc
2,444.00
6
0
912.00
F73A
Syncope and collapse w catastrophic or severe
cc
5,448.00
17
3
653.00
F73B
Syncope and collapse w/o catastrophic or
severe cc
2,568.00
7
1
732.00
F73C
Syncope and collapse, sameday
948.00
1
1
NA
F74A
Chest pain
2,546.00
8
1
696.00
F74B
Chest pain, <2 days
944.00
4
0
931.00
F75A
Other circulatory disorders w catastrophic cc
9,251.00
24
4
776.00
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
Max per day
rate (ex GST)
19
F75B
Other circulatory disorders w severe or
moderate cc
4,023.00
11
2
765.00
F75C
Other circulatory disorders w/o cc
2,178.00
5
0
823.00
F76A
Arrhythmia, cardiac arrest and conduction
disorders w cat or sev cc
5,927.00
15
3
786.00
F76B
Arrhythmia, cardiac arrest and conduction
disorders w/o cat or sev cc
2,485.00
6
0
845.00
F76C
Arrhythmia, cardiac arrest and conduction
disorders, sameday
592.00
1
1
NA
G01A
Rectal resection w catastrophic cc
19,621.00
32
5
1,100.00
G01B
Rectal resection w/o catastrophic cc
11,413.00
16
3
1,100.00
G02A
Major small and large bowel procedures w
catastrophic cc
17,902.00
33
5
1,052.00
G02B
Major small and large bowel procedures w/o
catastrophic cc
8,048.00
12
2
1,100.00
G03A
Stomach, oesophageal and duodenal
procedures w malignancy or w cat cc
18,014.00
26
4
1,100.00
G03B
Stomach, oesophageal and duodenal
procedures w/o malignancy w sev or mod cc
8,866.00
10
2
1,100.00
G03C
Stomach, oesophageal and duodenal
procedures w/o malignancy w/o cc
5,260.00
5
0
1,100.00
G04A
Peritoneal adhesiolysis w catastrophic cc
14,755.00
29
5
963.00
G04B
Peritoneal adhesiolysis w severe or moderate
cc
9,057.00
14
2
1,100.00
G04C
Peritoneal adhesiolysis w/o cc
5,023.00
7
1
1,100.00
G05A
Minor small and large bowel procedures w
catastrophic cc
8,103.00
22
4
688.00
G05B
Minor small and large bowel procedures w
severe or moderate cc
6,440.00
15
3
777.00
G05C
Minor small and large bowel procedures w/o
cc
3,810.00
9
1
770.00
G06Z
Pyloromyotomy
450.00
6
0
170.00
G07A
Appendicectomy w malignancy or peritonitis
or w catastrophic or severe cc
3,989.00
8
1
949.00
G07B
Appendicectomy w/o malignancy or
peritonitis w/o cat or sev cc
3,076.00
4
0
1,100.00
G10A
Hernia procedures w cc
3,813.00
8
1
915.00
G10B
Hernia procedures w/o cc
2,440.00
4
0
1,100.00
G11Z
Anal and stomal procedures
1,697.00
4
0
889.00
G12A
Other digestive system or procedures w
catastrophic cc
13,060.00
34
6
728.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
20
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
G12B
Other digestive system or procedures w
severe or moderate cc
6,292.00
11
2
1,100.00
G12C
Other digestive system or procedures w/o cc
3,053.00
5
0
1,100.00
G46A
Complex endoscopy w catastrophic cc
8,685.00
28
5
608.00
G46B
Complex endoscopy w/o catastrophic cc
3,035.00
7
1
882.00
G46C
Complex endoscopy, sameday
792.00
1
1
NA
G47A
Gastroscopy w catastrophic cc
6,676.00
28
5
470.00
G47B
Gastroscopy w/o catastrophic cc
2,940.00
8
1
761.00
G47C
Gastroscopy, sameday
527.00
1
1
NA
G48A
Colonoscopy w catastrophic or severe cc
5,377.00
17
3
622.00
G48B
Colonoscopy w/o catastrophic or severe cc
2,149.00
5
0
885.00
G48C
Colonoscopy, sameday
728.00
1
1
NA
G60A
Digestive malignancy w catastrophic cc
7,230.00
26
4
565.00
G60B
Digestive malignancy w/o catastrophic cc
3,086.00
9
1
680.00
G61A
Gastrointestinal haemorrhage w catastrophic
or severe cc
4,755.00
16
3
618.00
G61B
Gastrointestinal haemorrhage w/o
catastrophic or severe cc
2,038.00
6
0
732.00
G64A
Inflammatory bowel disease w cc
2,774.00
10
2
560.00
G64B
Inflammatory bowel disease w/o cc
427.00
4
0
319.00
G65A
Gastrointestinal obstruction w catastrophic or
severe cc
5,093.00
18
3
583.00
G65B
Gastrointestinal obstruction w/o catastrophic
or severe cc
2,413.00
8
1
656.00
G66A
Abdominal pain and mesenteric adenitis
1,794.00
6
0
617.00
G66B
Abdominal pain and mesenteric adenitis,
sameday
367.00
1
1
NA
G67A
Oesophagitis and gastroenteritis w
catastrophic or severe cc
4,645.00
15
2
622.00
G67B
Oesophagitis and gastroenteritis w/o
catastrophic or severe cc
1,809.00
6
0
643.00
G70A
Other digestive system disorders w
catastrophic or severe cc
4,869.00
17
3
599.00
G70B
Other digestive system disorders w/o
catastrophic or severe cc
2,238.00
8
1
630.00
G70C
Other digestive system disorders, sameday
480.00
1
1
NA
H01A
Pancreas, liver and shunt procedures w
catastrophic cc
25,088.00
34
6
1,100.00
H01B
Pancreas, liver and shunt procedures w/o
catastrophic cc
11,872.00
14
2
1,100.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
21
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
H02A
Major biliary tract procedures w catastrophic
cc
H02B
Major biliary tract procedures w/o
catastrophic cc
H05A
Hepatobiliary diagnostic procedures w
catastrophic cc
H05B
19,510.00
35
6
958.00
9,228.00
13
2
1,100.00
10,680.00
24
4
783.00
Hepatobiliary diagnostic procedures w/o
catastrophic cc
3,033.00
5
0
959.00
H06A
Other hepatobiliary and pancreas OR
procedures w catastrophic cc
9,834.00
21
4
847.00
H06B
Other hepatobiliary and pancreas OR
procedures w/o catastrophic cc
5,872.00
5
0
1,100.00
H07A
Open cholecystectomy w closed cde or w
catastrophic cc
13,109.00
26
4
929.00
H07B
Open cholecystectomy w/o closed cde w/o
catastrophic cc
6,018.00
11
2
986.00
H08A
Laparoscopic cholecystectomy w closed cde
or w cat or sev cc
5,507.00
10
2
986.00
H08B
Laparoscopic cholecystectomy w/o closed cde
w/o cat or sev cc
3,815.00
4
0
1,100.00
H40B
Endoscopic procedures for bleeding
oesophageal varices w/o cat cc
2,650.00
6
0
1,047.00
H43A
Ercp procedures w catastrophic or severe cc
8,472.00
19
3
831.00
H43B
Ercp procedures w/o catastrophic or severe cc
3,589.00
6
0
1,044.00
H43C
Ercp procedures, sameday
1,897.00
1
1
NA
H60A
Cirrhosis and alcoholic hepatitis w
catastrophic cc
8,638.00
28
5
606.00
H60B
Cirrhosis and alcoholic hepatitis w/o
catastrophic cc
4,025.00
13
2
631.00
H60C
Cirrhosis and alcoholic hepatitis, sameday
616.00
1
1
NA
H61A
Malignancy of hepatobiliary system and
pancreas w catastrophic cc
7,941.00
25
4
633.00
H61B
Malignancy of hepatobiliary system and
pancreas w/o catastrophic cc
4,487.00
13
2
733.00
H61C
Malignancy of hepatobiliary system and
pancreas, sameday
715.00
1
1
NA
H62A
Disorders of pancreas, except malignancy w
catastrophic or severe cc
7,027.00
19
3
755.00
H62B
Disorders of pancreas, except malignancy w/o
catastrophic or severe cc
2,089.00
7
1
638.00
H63A
Other disorders of liver w catastrophic cc
7,703.00
27
4
578.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
22
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
H63B
Other disorders of liver w/o catastrophic cc
3,293.00
11
2
641.00
H63C
Other disorders of liver, sameday
635.00
1
1
NA
H64A
Disorders of the biliary tract w cc
4,898.00
16
3
645.00
H64B
Disorders of the biliary tract w/o cc
1,963.00
7
1
644.00
H64C
Disorders of the biliary tract, sameday
572.00
1
1
NA
I01A
Bilateral and multiple major joint proc of
lower limb w revision or w cat cc
16,076.00
33
5
820.00
I01B
Bilateral and multiple major joint proc of
lower limb w/o revision w/o cat cc
12,224.00
15
2
1,100.00
I02A
Microvascular tissue transfers or (skin grafts w
cat or sev cc), excl hand
22,258.00
35
9
752.00
I02B
Skin grafts w/o cat or sev cc, excluding hand
4,733.00
8
1
1,026.00
I03A
Hip replacement w catastrophic cc
15,120.00
28
5
1,045.00
I03B
Hip replacement w/o catastrophic cc
10,703.00
13
2
1,100.00
I04A
Knee replacement w catastrophic or severe cc
10,801.00
17
3
1,100.00
I04B
Knee replacement w/o catastrophic or severe
cc
9,164.00
12
2
1,100.00
I05A
Other joint replacement w catastrophic or
severe cc
9,025.00
17
3
954.00
I05B
Other joint replacement w/o catastrophic or
severe cc
6,747.00
9
1
1,100.00
I06Z
Spinal fusion for deformity
17,086.00
20
3
1,100.00
I07Z
Amputation
16,645.00
35
6
868.00
I08A
Other hip and femur procedures w
catastrophic cc
15,212.00
35
6
746.00
I08B
Other hip and femur procedures w/o
catastrophic cc
6,148.00
9
1
1,100.00
I09A
Spinal fusion w catastrophic cc
20,098.00
30
5
1,100.00
I09B
Spinal fusion w/o catastrophic cc
11,183.00
13
2
1,100.00
I10A
Other back and neck procedures w
catastrophic or severe cc
11,098.00
17
3
1,095.00
I10B
Other back and neck procedures w/o
catastrophic or severe cc
6,768.00
8
1
1,100.00
I11Z
Limb lengthening procedures
6,199.00
9
1
1,100.00
I12A
Misc musculoskeletal procs for infect/inflam of
bone/joint w cat cc
16,765.00
35
8
684.00
I12B
Misc musculoskeletal procs for infect/inflam of
bone/joint w sev or mod cc
9,287.00
24
4
705.00
I12C
Misc musculoskeletal procs for infect/inflam of
bone/joint w/o cc
3,822.00
8
1
885.00
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
Max per day
rate (ex GST)
23
I13A
Humerus, tibia, fibula and ankle procedures w
cc
8,040.00
18
3
827.00
I13B
Humerus, tibia, fibula and ankle procedures
w/o cc, age >=17
3,453.00
5
0
1,100.00
I13C
Humerus, tibia, fibula and ankle procedures
w/o cc, age <17
2,559.00
4
0
1,100.00
I15Z
Cranio-facial surgery
7,545.00
10
2
1,100.00
I16Z
Other shoulder procedures
3,194.00
4
0
1,100.00
I17A
Maxillo-facial surgery w cc
2,542.00
7
1
393.00
I17B
Maxillo-facial surgery w/o cc
3,552.00
4
0
1,100.00
I18Z
Other knee procedures
1,779.00
4
0
1,100.00
I19A
Other elbow and forearm procedures w cc
4,712.00
12
2
696.00
I19B
Other elbow and forearm procedures w/o cc
2,642.00
4
0
1,100.00
I20Z
Other foot procedures
2,669.00
4
0
1,100.00
I21Z
Local excision and removal of internal fixation
devices of hip and femur
1,871.00
4
0
886.00
I23Z
Local excision and removal of internal fixation
devices, except hip and femur
1,454.00
4
0
887.00
I24Z
Arthroscopy
1,756.00
4
0
1,004.00
I25A
Bone and joint diagnostic procedures
including biopsy w cc
6,600.00
22
4
590.00
I25B
Bone and joint diagnostic procedures
including biopsy w/o cc
2,226.00
5
0
771.00
I27A
Soft tissue procedures w catastrophic or
severe cc
5,866.00
18
3
625.00
I27B
Soft tissue procedures w/o catastrophic or
severe cc
2,688.00
4
0
1,069.00
I27C
Soft tissue procedures, sameday
1,454.00
1
1
NA
I28A
Other musculoskeletal procedures w cc
7,364.00
18
3
781.00
I28B
Other musculoskeletal procedures w/o cc
2,391.00
4
0
1,100.00
I29Z
Knee reconstructions, and revisions of
reconstructions
2,453.00
4
0
1,100.00
I30Z
Hand procedures
1,644.00
4
0
945.00
I31A
Revision of hip replacement for infect/inflam
of joint prosth or w cat cc
19,363.00
34
6
1,035.00
I31B
Revision of hip replacement not for
infect/inflam of joint prosth w/o cat cc
13,323.00
16
3
1,100.00
I32A
Revision of knee replacement for infect/inflam
of joint prosth or w cat cc
14,551.00
31
5
846.00
I32B
Revision of knee replacement not for
infect/inflam of joint prosth w/o cat cc
9,755.00
13
2
1,100.00
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
I40Z
Infusions for musculoskeletal disorders,
1
1
ReturnToWorkSA - Private hospital fee schedule 2015-16
724.00
Max per day
rate (ex GST)
NA
24
sameday
I60Z
Femoral shaft fractures
4,756.00
17
3
564.00
I61A
Distal femoral fractures w cc
10,323.00
34
6
613.00
I61B
Distal femoral fractures w/o cc
6,746.00
14
2
979.00
I63A
Sprains, strains and dislocations of hip, pelvis
and thigh w cc
5,161.00
19
3
558.00
I63B
Sprains, strains and dislocations of hip, pelvis
and thigh w/o cc
2,383.00
7
1
678.00
I64A
Osteomyelitis w catastrophic or severe cc
9,846.00
35
6
535.00
I64B
Osteomyelitis w/o catastrophic or severe cc
6,447.00
24
4
532.00
I65A
Musculoskeletal malignant neoplasms w
radiotherapy or w cat cc
9,096.00
32
5
574.00
I65B
Musculoskeletal malignant neoplasms w/o
radiotherapy w/o cat cc
5,951.00
17
3
709.00
I66A
Inflammatory musculoskeletal disorders w
catastrophic or severe cc
7,461.00
24
4
628.00
I66B
Inflammatory musculoskeletal disorders w/o
catastrophic or severe cc
3,659.00
11
2
653.00
I67A
Septic arthritis w catastrophic or severe cc
9,242.00
35
6
534.00
I67B
Septic arthritis w/o catastrophic or severe cc
4,200.00
19
3
453.00
I68A
Non-surgical spinal disorders w cc
6,794.00
23
4
605.00
I68B
Non-surgical spinal disorders w/o cc
3,405.00
10
2
711.00
I69A
Bone diseases and arthropathies w
catastrophic or severe cc
6,699.00
22
4
633.00
I69B
Bone diseases and arthropathies w/o
catastrophic or severe cc
3,557.00
11
2
691.00
I71A
Other musculotendinous disorders w
catastrophic or severe cc
6,172.00
22
4
580.00
I71B
Other musculotendinous disorders w/o
catastrophic or severe cc
2,716.00
8
1
688.00
I72A
Specific musculotendinous disorders w
catastrophic or severe cc
6,200.00
21
3
595.00
I72B
Specific musculotendinous disorders w/o
catastrophic or severe cc
2,823.00
9
1
621.00
I73A
Aftercare of musculoskeletal implants or
prostheses w cat or sev cc
10,073.00
35
6
529.00
I73B
Aftercare of musculoskeletal implants or
prostheses w/o cat or sev cc
4,267.00
14
2
612.00
I74A
Injuries to forearm, wrist, hand and foot w cc
5,979.00
23
4
540.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
25
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
I74B
Injuries to forearm, wrist, hand and foot w/o
cc
1,790.00
6
0
668.00
I75A
Injuries to shoulder, arm, elbow, knee, leg and
ankle w cc
8,435.00
28
5
610.00
I75B
Injuries to shoulder, arm, elbow, knee, leg and
ankle w/o cc
3,383.00
11
2
649.00
I76A
Other musculoskeletal disorders w
catastrophic or severe cc
5,931.00
23
4
531.00
I76B
Other musculoskeletal disorders w/o
catastrophic or severe cc
3,525.00
11
2
658.00
I77A
Fractures of pelvis w catastrophic or severe cc
9,927.00
31
5
639.00
I77B
Fractures of pelvis w/o catastrophic or severe
cc
6,506.00
20
3
675.00
I78A
Fractures of neck of femur w catastrophic or
severe cc
9,958.00
35
6
577.00
I78B
Fractures of neck of femur w/o catastrophic or
severe cc
6,009.00
19
3
637.00
I79A
Pathological fractures w catastrophic cc
12,133.00
35
7
553.00
I79B
Pathological fractures w/o catastrophic cc
6,814.00
22
4
630.00
I80Z
Femoral fractures, transferred to acute facility
<2 days
732.00
4
0
732.00
I81Z
Musculoskeletal injuries, sameday
500.00
1
1
NA
I82Z
Other sameday treatment for musculoskeletal
disorders
827.00
4
0
548.00
J01A
Microvas tiss transf for skin, subcut tiss &
breast dsrds w cat or sev cc
16,238.00
23
4
1,100.00
J01B
Microvas tiss transf for skin, subcut tiss &
breast dsrds w/o cat or sev cc
13,299.00
15
2
1,100.00
J06A
Major procedures for malignant breast
disorders
4,501.00
6
0
1,100.00
J06B
Major procedures for non-malignant breast
disorders
3,504.00
4
0
1,100.00
J07A
Minor procedures for malignant breast
disorders
1,940.00
4
0
1,100.00
J07B
Minor procedures for non-malignant breast
disorders
1,393.00
4
0
816.00
J08A
Other skin grafts and debridement procedures
w cc
7,142.00
17
3
748.00
J08B
Other skin grafts and debridement procedures
w/o cc
2,970.00
5
0
1,037.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
26
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
J08C
Other skin grafts and debridement
procedures, sameday
1,531.00
1
1
NA
J09Z
Perianal and pilonidal procedures
1,721.00
4
0
825.00
J10Z
Plastic or procedures for skin, subcutaneous
tissue and breast disorders
1,955.00
4
0
949.00
J11Z
Other skin, subcutaneous tissue and breast
procedures
1,125.00
4
0
697.00
J12A
Lower limb procs w ulcer/cellulitis w cat cc
18,215.00
35
8
675.00
J12B
Lower limb procs w ulcer/cellulitis w/o cat cc w
skin graft/flap repair
10,626.00
27
4
746.00
J12C
Lower limb procs w ulcer/cellulitis w/o cat cc
w/o skin graft/flap repair
7,264.00
17
3
792.00
J13A
Lwr limb procs w/o ulcer/cellulitis w (skin
grafts and sev cc) or w cat cc
8,749.00
23
4
704.00
J13B
Lwr limb procs w/o ulcer/cellulitis w/o (skin
grafts and sev cc) w/o cat cc
3,430.00
7
1
801.00
J14Z
Major breast reconstructions
7,684.00
13
2
1,037.00
J60A
Skin ulcers w catastrophic cc
10,719.00
35
7
549.00
J60B
Skin ulcers w/o catastrophic cc
7,823.00
24
4
658.00
J60C
Skin ulcers, sameday
270.00
1
1
NA
J62A
Malignant breast disorders
2,759.00
9
1
682.00
J62B
Malignant breast disorders, sameday
366.00
1
1
NA
J63A
Non-malignant breast disorders
2,094.00
7
1
605.00
J63B
Non-malignant breast disorders, sameday
1,031.00
1
1
NA
J64A
Cellulitis w catastrophic or severe cc
7,076.00
24
4
611.00
J64B
Cellulitis w/o catastrophic or severe cc
3,074.00
11
2
594.00
J65A
Trauma to skin, subcutaneous tissue and
breast w cat or sev cc
5,738.00
20
3
570.00
J65B
Trauma to skin, subcutaneous tissue and
breast w/o cat or sev cc
3,167.00
10
2
687.00
J65C
Trauma to skin, subcutaneous tissue and
breast, sameday
657.00
1
1
NA
J67A
Minor skin disorders
3,052.00
10
2
627.00
J67B
Minor skin disorders, sameday
788.00
1
1
NA
J68A
Major skin disorders w catastrophic or severe
cc
6,939.00
24
4
599.00
J68B
Major skin disorders w/o catastrophic or
severe cc
3,592.00
11
2
675.00
J68C
Major skin disorders, sameday
310.00
1
1
NA
J69A
Skin malignancy w catastrophic cc
9,250.00
32
5
594.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
27
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
J69B
Skin malignancy w/o catastrophic cc
6,093.00
20
3
629.00
J69C
Skin malignancy, sameday
486.00
1
1
NA
K01A
OR procedures for diabetic complications w
catastrophic cc
22,453.00
35
11
633.00
K01B
OR procedures for diabetic complications w/o
catastrophic cc
13,459.00
29
5
872.00
K02A
Pituitary procedures w cc
14,888.00
18
3
1,100.00
K02B
Pituitary procedures w/o cc
11,677.00
12
2
1,100.00
K03Z
Adrenal procedures
8,067.00
10
2
1,100.00
K05A
Parathyroid procedures w catastrophic or
severe cc
6,949.00
14
2
897.00
K05B
Parathyroid procedures w/o catastrophic or
severe cc
3,688.00
4
0
1,100.00
K06A
Thyroid procedures w catastrophic or severe
cc
5,780.00
8
1
1,100.00
K06B
Thyroid procedures w/o catastrophic or severe
cc
4,129.00
4
0
1,100.00
K08Z
Thyroglossal procedures
2,361.00
4
0
1,100.00
K09A
Other endocrine, nutritional and metabolic or
procs w catastrophic cc
19,353.00
35
9
657.00
K09B
Other endocrine, nutritional and metabolic or
procs w severe or moderate cc
9,702.00
19
3
894.00
K09C
Other endocrine, nutritional and metabolic or
procs w/o cc
6,064.00
6
0
1,100.00
K10A
Revisional and open bariatric procedures w cc
8,074.00
12
2
1,100.00
K10B
Revisional and open bariatric procedures w/o
cc
5,585.00
6
0
1,100.00
K11A
Major laparoscopic bariatric procedures w cc
4,872.00
8
1
582.00
K11B
Major laparoscopic bariatric procedures w/o cc
5,695.00
6
0
1,100.00
K12Z
Other bariatric procedures
5,368.00
5
0
1,100.00
K13Z
Plastic or procedures for endocrine, nutritional
and metabolic disorders
5,734.00
7
1
1,100.00
K40A
Endoscopic and investigative procs for
metabolic disorders w cat cc
9,098.00
32
5
557.00
K40B
Endoscopic and investigative procs for
metabolic disorders w/o cat cc
2,825.00
8
1
694.00
K40C
Endoscopic and investigative procs for
metabolic disorders, sameday
837.00
1
1
NA
K60A
Diabetes w catastrophic or severe cc
7,481.00
24
4
626.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
28
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
K60B
Diabetes w/o catastrophic or severe cc
3,073.00
10
2
622.00
K60C
Diabetes, sameday
257.00
1
1
NA
K61Z
Severe nutritional disturbance
7,413.00
21
3
738.00
K62A
Miscellaneous metabolic disorders w
catastrophic or severe cc
6,257.00
19
3
662.00
K62B
Miscellaneous metabolic disorders w/o
catastrophic or severe cc
2,923.00
9
1
685.00
K62C
Miscellaneous metabolic disorders, sameday
413.00
1
1
NA
K63A
Inborn errors of metabolism w catastrophic or
severe cc
2,888.00
15
2
403.00
K63B
Inborn errors of metabolism w/o catastrophic
or severe cc
1,043.00
4
0
750.00
K64A
Endocrine disorders w catastrophic or severe
cc
7,525.00
23
4
671.00
K64B
Endocrine disorders w/o catastrophic or
severe cc
2,637.00
9
1
653.00
K64C
Endocrine disorders, sameday
155.00
1
1
NA
L02A
Operative insertion of peritoneal catheter for
dialysis w cat or sev cc
5,138.00
12
2
727.00
L02B
Operative insertion of peritoneal catheter for
dialysis w/o cat or sev cc
2,455.00
4
0
1,059.00
L03A
Kidney, ureter and major bladder procedures
for neoplasm w cat cc
18,447.00
30
5
1,100.00
L03B
Kidney, ureter and major bladder procedures
for neoplasm w sev cc
13,895.00
17
3
1,100.00
L03C
Kidney, ureter and major bladder procedures
for neoplasm w/o cat or sev cc
8,383.00
10
2
1,100.00
L04A
Kidney, ureter and major bladder procedures
for non-neoplasm w cat cc
11,699.00
26
4
842.00
L04B
Kidney, ureter and major bladder procedures
for non-neoplasm w/o cat cc
4,124.00
5
0
1,100.00
L04C
Kidney, ureter and major bladder procedures
for non-neoplasm, sameday
1,538.00
1
1
NA
L05A
Transurethral prostatectomy for urinary
disorder w cat or sev cc
9,895.00
22
4
832.00
L05B
Transurethral prostatectomy for urinary
disorder w/o cat or sev cc
4,366.00
7
1
1,100.00
L06A
Minor bladder procedures w catastrophic or
severe cc
7,141.00
16
3
839.00
L06B
Minor bladder procedures w/o catastrophic or
severe cc
2,439.00
4
0
1,083.00
L07A
Other transurethral procedures w cc
2,525.00
7
1
709.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
29
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
L07B
Other transurethral procedures w/o cc
1,476.00
4
0
947.00
L08A
Urethral procedures w cc
2,628.00
6
0
772.00
L08B
Urethral procedures w/o cc
1,444.00
4
0
833.00
L09A
Other procedures for kidney and urinary tract
disorders w cat cc
18,937.00
35
6
974.00
L09B
Other procedures for kidney and urinary tract
disorders w sev cc
5,756.00
11
2
962.00
L09C
Other procedures for kidney and urinary tract
disorders w/o cat or sev cc
2,923.00
4
0
1,100.00
L40Z
Ureteroscopy
1,600.00
4
0
893.00
L41Z
Cystourethroscopy for urinary disorder,
sameday
795.00
1
1
NA
L42Z
ESW lithotripsy
2,546.00
4
0
1,100.00
L60A
Kidney failure w catastrophic cc
10,307.00
27
4
762.00
L60B
Kidney failure w severe cc
6,255.00
17
3
744.00
L60C
Kidney failure w/o catastrophic or severe cc
3,555.00
10
2
734.00
L61Z
Haemodialysis
355.00
4
0
351.00
L62A
Kidney and urinary tract neoplasms w
catastrophic or severe cc
6,721.00
22
4
634.00
L62B
Kidney and urinary tract neoplasms w/o
catastrophic or severe cc
1,957.00
6
0
713.00
L63A
Kidney and urinary tract infections w
catastrophic or severe cc
6,606.00
21
3
637.00
L63B
Kidney and urinary tract infections w/o
catastrophic or severe cc
2,966.00
9
1
679.00
L64A
Urinary stones and obstruction w catastrophic
or severe cc
3,509.00
11
2
625.00
L64B
Urinary stones and obstruction w/o
catastrophic or severe cc
1,481.00
4
0
742.00
L64C
Urinary stones and obstruction, sameday
555.00
1
1
NA
L65A
Kidney and urinary tract signs and symptoms
w catastrophic or severe cc
5,072.00
16
3
649.00
L65B
Kidney and urinary tract signs and symptoms
w/o catastrophic or severe cc
1,579.00
5
0
670.00
L66Z
Urethral stricture
1,294.00
4
0
739.00
L67A
Other kidney and urinary tract disorders w
catastrophic or severe cc
4,800.00
14
2
706.00
L67B
Other kidney and urinary tract disorders w/o
catastrophic or severe cc
1,604.00
5
0
706.00
L67C
Other kidney and urinary tract disorders,
sameday
435.00
1
1
NA
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
30
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
M01A
Major male pelvic procedures w catastrophic
or severe cc
M01B
10,380.00
13
2
1,100.00
Major male pelvic procedures w/o
catastrophic or severe cc
9,096.00
7
1
1,100.00
M02A
Transurethral prostatectomy for reproductive
system disorder w cat/sev cc
6,800.00
14
2
936.00
M02B
Transurethral prostatectomy for reproductive
system disorder w/o cat/sev cc
3,798.00
6
0
1,100.00
M03Z
Penis procedures
2,005.00
4
0
1,018.00
M04Z
Testes procedures
1,648.00
4
0
957.00
M05Z
Circumcision
1,053.00
4
0
661.00
M06A
Other male reproductive system OR
procedures w cc
2,874.00
7
1
773.00
M06B
Other male reproductive system OR
procedures w/o cc
1,836.00
4
0
1,100.00
M40Z
Cystourethroscopy for male reproductive
system disorder, sameday
768.00
1
1
NA
M60A
Male reproductive system malignancy w
catastrophic or severe cc
7,183.00
24
4
613.00
M60B
Male reproductive system malignancy w/o
catastrophic or severe cc
847.00
4
0
543.00
M61A
Benign prostatic hypertrophy w cc
2,659.00
8
1
646.00
M61B
Benign prostatic hypertrophy w/o cc
802.00
4
0
519.00
M62A
Male reproductive system inflammation w cc
3,193.00
12
2
561.00
M62B
Male reproductive system inflammation w/o
cc
1,514.00
5
0
589.00
M63Z
Male sterilisation procedures
910.00
4
0
714.00
M64Z
Other male reproductive system disorders
954.00
4
0
522.00
N01A
Pelvic evisceration and radical vulvectomy w
catastrophic or severe cc
13,711.00
27
4
941.00
N01B
Pelvic evisceration and radical vulvectomy w/o
catastrophic or severe cc
8,454.00
10
2
1,100.00
N04A
Hysterectomy for non-malignancy w
catastrophic or severe cc
5,945.00
10
2
1,028.00
N04B
Hysterectomy for non-malignancy w/o
catastrophic or severe cc
5,275.00
7
1
1,100.00
N05A
Oophorectomy and complex fallopian tube
procs for non-malig w cat or sev cc
6,256.00
10
2
1,100.00
N05B
Oophorectomy and complex fallopian tube
procs for non-malig w/o cat or sev cc
3,480.00
4
0
1,100.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
31
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
N06Z
Female reproductive system reconstructive
procedures
3,827.00
6
0
1,100.00
N07A
Other uterus and adnexa procedures for nonmalignancy
2,643.00
4
0
1,100.00
N07B
Other uterus and adnexa procedures for nonmalignancy, sameday
1,424.00
1
1
NA
N08Z
Endoscopic and laparoscopic procedures,
female reproductive system
1,716.00
4
0
976.00
N09Z
Other vagina, cervix and vulva procedures
1,115.00
4
0
682.00
N10Z
Diagnostic curettage and diagnostic
hysteroscopy
962.00
4
0
691.00
N11Z
Other female reproductive system or
procedures
348.00
4
0
236.00
N12A
Uterus and adnexa procedures for malignancy
w catastrophic cc
11,580.00
22
4
1,004.00
N12B
Uterus and adnexa procedures for malignancy
w/o catastrophic cc
5,960.00
8
1
1,100.00
N60A
Female reproductive system malignancy w
catastrophic cc
8,172.00
28
5
584.00
N60B
Female reproductive system malignancy w/o
catastrophic cc
2,706.00
8
1
681.00
N61Z
Female reproductive system infections
1,515.00
6
0
588.00
N62Z
Menstrual and other female reproductive
system disorders
748.00
4
0
508.00
O01A
Caesarean delivery w catastrophic cc
8,167.00
19
3
845.00
O01B
Caesarean delivery w severe cc
5,589.00
12
2
941.00
O01C
Caesarean delivery w/o catastrophic or severe
cc
5,228.00
10
2
1,063.00
O02A
Vaginal delivery w OR procedures w
catastrophic or severe cc
4,704.00
11
2
845.00
O02B
Vaginal delivery w OR procedures w/o
catastrophic or severe cc
3,478.00
9
1
820.00
O03A
Ectopic pregnancy w cc
2,605.00
5
0
1,003.00
O03B
Ectopic pregnancy w/o cc
2,254.00
4
0
1,100.00
O04A
Postpartum and post abortion w OR
procedures w catastrophic or severe cc
2,529.00
9
1
513.00
O04B
Postpartum and post abortion w OR
procedures w/o catastrophic or severe cc
1,860.00
5
0
774.00
O04C
Postpartum and post abortion w OR
procedures, sameday
1,085.00
1
1
NA
O05Z
Abortion w OR procedures
905.00
4
0
697.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
32
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
O60A
Vaginal delivery w catastrophic or severe cc
3,885.00
11
2
732.00
O60B
Vaginal delivery w/o catastrophic or severe cc
3,831.00
9
1
883.00
O60C
Vaginal delivery, single uncomplicated
3,492.00
8
1
920.00
O61Z
Postpartum and post abortion w/o OR
procedures
1,792.00
7
1
591.00
O63Z
Abortion w/o OR procedures
655.00
4
0
555.00
O66A
Antenatal and other obstetric admissions w
catastrophic or severe cc
2,547.00
10
2
527.00
O66B
Antenatal and other obstetric admissions w/o
catastrophic or severe cc
1,441.00
5
0
681.00
O66C
Antenatal and other obstetric admissions,
sameday
319.00
1
1
NA
P06A
Neonate, admwt >=2500g w significant OR
procedure w multiple major problems
2,694.00
35
9
98.00
P06B
Neonate, admwt >=2500g w significant OR
procedure w/o multiple major problems
2,286.00
20
3
203.00
P60A
Neonate w/o sig OR proc, died or transferred
to acute facility <5 days
723.00
4
0
413.00
P60B
Neonate w/o sig OR proc, died or transferred
to acute facility sameday
131.00
1
1
NA
P63B
Neonate, admwt 1000-1249g w/o sig OR proc
>=32 completed wks gestation
2,825.00
31
5
184.00
P64A
Neonate, admwt 1250-1499g w/o sig OR proc
<32 completed wks gestation
17,921.00
35
10
570.00
P64B
Neonate, admwt 1250-1499g w/o sig OR proc
>=32 completed wks gestation
13,768.00
35
8
547.00
P65B
Neonate, admwt 1500-1999g w/o significant
OR proc w major problem
16,359.00
35
8
653.00
P65C
Neonate, admwt 1500-1999g w/o significant
OR proc w other problem
12,233.00
35
7
558.00
P65D
Neonate, admwt 1500-1999g w/o significant
OR proc w/o problem
10,876.00
35
6
589.00
P66A
Neonate, admwt 2000-2499g w/o significant
OR proc w multiple major problems
6,365.00
35
6
355.00
P66B
Neonate, admwt 2000-2499g w/o significant
OR proc w major problem
10,155.00
33
5
618.00
P66C
Neonate, admwt 2000-2499g w/o significant
OR proc w other problem
7,572.00
27
4
575.00
P66D
Neonate, admwt 2000-2499g w/o significant
OR proc w/o problem
2,713.00
11
2
533.00
P67A
Neonate, admwt >=2500g w/o sig OR proc <37
comp wks gest w mult major probs
5,546.00
30
5
382.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
33
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
P67B
Neonate, admwt >=2500g w/o sig OR proc <37
comp wks gest w major problem
6,144.00
23
4
548.00
P67C
Neonate, admwt >=2500g w/o sig OR proc <37
comp wks gest w other problem
4,745.00
20
3
499.00
P67D
Neonate, admwt >=2500g w/o sig OR proc <37
comp wks gest w/o problem
1,742.00
10
2
386.00
P68A
Neonate, admwt >=2500g w/o sig OR proc
>=37 comp wks gest w mult major probs
2,687.00
20
3
275.00
P68B
Neonate, admwt >=2500g w/o sig OR proc
>=37 comp wks gest w major problem
2,671.00
10
2
584.00
P68C
Neonate, admwt >=2500g w/o sig OR proc
>=37 comp wks gest w other problem
1,641.00
7
1
494.00
P68D
Neonate, admwt >=2500g w/o sig OR proc
>=37 comp wks gest w/o problem
128.00
7
1
36.00
Q01A
Splenectomy w catastrophic or severe cc
11,275.00
16
3
1,100.00
Q01B
Splenectomy w/o catastrophic or severe cc
6,998.00
9
1
1,100.00
Q02A
Blood and immune system disorders w other
OR procedures w cat or sev cc
11,539.00
25
4
852.00
Q02B
Blood and immune system disorders w other
OR procedures w/o cat or sev cc
2,152.00
4
0
928.00
Q60A
Reticuloendothelial and immunity disorders w
catastrophic or severe cc
5,884.00
17
3
703.00
Q60B
Reticuloendothelial and immunity disorders
w/o catastrophic or severe cc
2,089.00
8
1
587.00
Q60C
Reticuloendothelial and immunity disorders,
sameday
473.00
1
1
NA
Q61A
Red blood cell disorders w catastrophic or
severe cc
4,923.00
15
2
672.00
Q61B
Red blood cell disorders w/o catastrophic or
severe cc
1,911.00
5
0
750.00
Q61C
Red blood cell disorders, sameday
582.00
1
1
NA
Q62A
Coagulation disorders
3,744.00
12
2
651.00
Q62B
Coagulation disorders, sameday
683.00
1
1
NA
R01A
Lymphoma and leukaemia w major OR
procedures w catastrophic or severe cc
20,224.00
35
6
1,000.00
R01B
Lymphoma and leukaemia w major OR
procedures w/o catastrophic or severe cc
5,534.00
8
1
1,100.00
R02A
Other neoplastic disorders w major OR
procedures w catastrophic cc
14,691.00
27
4
1,033.00
R02B
Other neoplastic disorders w major OR
procedures w severe or moderate cc
9,116.00
13
2
1,100.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
34
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
R02C
Other neoplastic disorders w major OR
procedures w/o cc
5,358.00
8
1
1,100.00
R03A
Lymphoma and leukaemia w other OR
procedures w catastrophic or severe cc
15,690.00
35
7
748.00
R03B
Lymphoma and leukaemia w other OR
procedures w/o catastrophic or severe cc
4,189.00
7
1
1,059.00
R03C
Lymphoma and leukaemia w other OR
procedures, sameday
1,355.00
1
1
NA
R04A
Other neoplastic disorders w other OR
procedures w cc
5,207.00
11
2
875.00
R04B
Other neoplastic disorders w other OR
procedures w/o cc
2,258.00
4
0
1,049.00
R60A
Acute leukaemia w catastrophic cc
17,871.00
35
8
726.00
R60B
Acute leukaemia w/o catastrophic cc
5,027.00
14
2
711.00
R60C
Acute leukaemia, sameday
359.00
1
1
NA
R61A
Lymphoma and non-acute leukaemia w
catastrophic cc
12,132.00
35
6
643.00
R61B
Lymphoma and non-acute leukaemia w/o
catastrophic cc
3,358.00
10
2
720.00
R61C
Lymphoma and non-acute leukaemia,
sameday
403.00
1
1
NA
R62A
Other neoplastic disorders w cc
5,859.00
19
3
620.00
R62B
Other neoplastic disorders w/o cc
1,987.00
7
1
561.00
R63Z
Chemotherapy
432.00
4
0
420.00
S65D
Human immunodeficiency virus, sameday
326.00
1
1
NA
T01A
Infectious and parasitic diseases w OR
procedures w catastrophic cc
20,859.00
35
8
793.00
T01B
Infectious and parasitic diseases w OR
procedures w severe or moderate cc
9,582.00
22
4
818.00
T01C
Infectious and parasitic diseases w OR
procedures w/o cc
5,088.00
11
2
827.00
T40Z
Infectious and parasitic diseases w ventilator
support
12,563.00
27
4
958.00
T60A
Septicaemia w catastrophic cc
9,847.00
29
5
686.00
T60B
Septicaemia w/o catastrophic cc
5,437.00
18
3
630.00
T61A
Postoperative and post-traumatic infections w
catastrophic or severe cc
5,219.00
20
3
537.00
T61B
Postoperative and post-traumatic infections
w/o catastrophic or severe cc
3,417.00
11
2
624.00
T62A
Fever of unknown origin w cc
3,553.00
12
2
609.00
T62B
Fever of unknown origin w/o cc
1,894.00
7
1
622.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
35
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
T63A
Viral illnesses w cc
3,515.00
13
2
545.00
T63B
Viral illnesses w/o cc
1,530.00
5
0
643.00
T64A
Other infectious and parasitic diseases w
catastrophic cc
8,273.00
31
5
525.00
T64B
Other infectious and parasitic diseases w
severe or moderate cc
5,176.00
19
3
565.00
T64C
Other infectious and parasitic diseases w/o cc
1,873.00
7
1
545.00
U40Z
Mental health treatment w ECT, sameday
337.00
1
1
NA
U60Z
Mental health treatment w/o ECT, sameday
278.00
1
1
NA
U61A
Schizophrenia disorders, involuntary
admission
6,399.00
35
8
276.00
U61B
Schizophrenia disorders
10,997.00
35
7
528.00
U62A
Paranoia & acute psyc disorders, involuntary
admission or w cat or sev cc
10,436.00
35
7
499.00
U62B
Paranoia & acute psyc disorders w/o cat or sev
cc
9,716.00
35
6
530.00
U63A
Major affective disorders age >=70 or w
catastrophic or severe cc
12,661.00
35
7
577.00
U63B
Major affective disorders age <70 w/o
catastrophic or severe cc
11,327.00
35
6
584.00
U64Z
Other affective and somatoform disorders
11,696.00
35
6
629.00
U65Z
Anxiety disorders
9,430.00
32
5
607.00
U66Z
Eating and obsessive-compulsive disorders
15,567.00
35
9
577.00
U67Z
Personality disorders and acute reactions
10,261.00
34
6
614.00
U68Z
Childhood mental disorders
6,310.00
30
5
430.00
V60A
Alcohol intoxication and withdrawal w cc
6,519.00
20
3
654.00
V60B
Alcohol intoxication and withdrawal w/o cc
5,766.00
18
3
649.00
V61Z
Drug intoxication and withdrawal
7,032.00
22
4
646.00
V62Z
Alcohol use and dependence
9,450.00
32
5
598.00
V63Z
Opioid use and dependence
8,726.00
31
5
568.00
V64Z
Other drug use and dependence
9,904.00
35
6
578.00
V65Z
Treatment for alcohol disorders, sameday
272.00
1
1
NA
V66Z
Treatment for drug disorders, sameday
219.00
1
1
NA
W02A
Hip, femur & lower limb procs for mult
significant trauma w cat or sev cc
14,062.00
35
8
522.00
W02B
Hip, femur & lower limb procs for mult
significant trauma w/o cat or sev cc
13,750.00
21
3
1,100.00
W04A
Multiple significant trauma w other OR procs
w catastrophic or severe cc
13,948.00
35
9
523.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
36
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
W61A
Multiple trauma w/o OR procedures w
catastrophic or severe cc
7,549.00
35
6
432.00
W61B
Multiple trauma w/o OR procedures w/o
catastrophic or severe cc
7,102.00
22
4
650.00
X02A
Microvascular tiss transfer or (skin graft w
cat/sev cc) for injuries to hand
3,849.00
5
0
916.00
X02B
Skin graft for injuries to hand w/o catastrophic
or severe cc
2,462.00
4
0
924.00
X04A
Other procedures for injuries to lower limb w
catastrophic or severe cc
7,337.00
21
3
615.00
X04B
Other procedures for injuries to lower limb
w/o catastrophic or severe cc
2,843.00
5
0
950.00
X05A
Other procedures for injuries to hand w cc
3,609.00
9
1
728.00
X05B
Other procedures for injuries to hand w/o cc
1,868.00
4
0
845.00
X06A
Other procedures for other injuries w
catastrophic or severe cc
8,512.00
17
3
924.00
X06B
Other procedures for other injuries w/o
catastrophic or severe cc
3,013.00
4
0
1,100.00
X07A
Skin graft for injuries excl hand w
microvascular tiss trans or w cat/sev cc
12,050.00
30
5
709.00
X07B
Skin graft for injuries excl hand w/o
microvascular tiss trans w/o cat/sev cc
5,477.00
10
2
982.00
X60A
Injuries w catastrophic or severe cc
6,380.00
21
3
633.00
X60B
Injuries w/o catastrophic or severe cc
2,508.00
8
1
646.00
X61Z
Allergic reactions
1,056.00
4
0
668.00
X62A
Poisoning/toxic effects of drugs and other
substances w cat or sev cc
4,285.00
18
3
488.00
X62B
Poisoning/toxic effects of drugs and other
substances w/o cat or sev cc
1,312.00
5
0
529.00
X63A
Sequelae of treatment w catastrophic or
severe cc
4,315.00
13
2
654.00
X63B
Sequelae of treatment w/o catastrophic or
severe cc
1,626.00
6
0
593.00
X64A
Other injuries, poisonings and toxic effects w
catastrophic or severe cc
3,195.00
10
2
671.00
X64B
Other injuries, poisonings and toxic effects
w/o catastrophic or severe cc
862.00
4
0
535.00
Y02C
Skin grafts for other burns w/o catastrophic or
severe cc, non emergency
3,815.00
7
1
898.00
Y03Z
Other or procedures for other burns
3,040.00
7
1
700.00
Y62A
Other burns w cc
4,364.00
14
2
623.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
37
Item no
Description
Max fee
(ex GST)
Upper trim
point days
Lower trim
point days
Y62B
Other burns w/o cc
3,252.00
13
2
523.00
Z01A
Other contacts w health services w OR
procedures
3,749.00
1
1
NA
Z01B
Other contacts w health services w OR
procedures, sameday
1,113.00
1
1
NA
Z40Z
Other contacts w health services w
endoscopy, sameday
679.00
4
0
572.00
Z60Z
Rehabilitation
2,468.00
9
1
593.00
Z61A
Signs and symptoms
3,242.00
10
2
696.00
Z61B
Signs and symptoms, sameday
534.00
1
1
NA
Z63A
Other follow up after surgery or medical care
w catastrophic cc
7,991.00
30
5
541.00
Z63B
Other follow up after surgery or medical care
w/o catastrophic cc
3,202.00
12
2
558.00
Z64A
Other factors influencing health status
1,831.00
11
2
329.00
Z64B
Other factors influencing health status,
sameday
357.00
1
1
NA
Z65Z
Congenital anomalies and problems arising
from neonatal period
3,018.00
16
3
382.00
Z66Z
Sleep disorders
1,150.00
4
0
661.00
ReturnToWorkSA - Private hospital fee schedule 2015-16
Max per day
rate (ex GST)
38
General information
Account and invoicing standards
All amounts listed in this booklet are exclusive of GST. If applicable, ReturnToWorkSA will pay to the provider an amount
on account of the provider’s GST liability in addition to the GST exclusive fee. Suppliers should provide ReturnToWorkSA
with a tax invoice where the amounts are subject to GST.
For all invoices, whether a tax invoice or not, the following information should be provided:
 hospital name and address, provider details – name, Medicare provider number (if applicable) and/or
ReturnToWorkSA provider number (if known)
 invoice number and invoice date
 Australian Business Number (ABN)
 worker’s surname and given name(s)
 claim number (if known)
 brief description of the injury to which the services relate
 employer name (if known)
 each service itemised separately in accordance with this fee schedule including:

-
date of service and commencement time
-
service item number and service description
-
charge for the service in accordance with this fee schedule
-
total charge for invoiced items plus any GST that may be applicable.
bank account details for electronic funds transfer (EFT).
Invoices that do not meet these standards may be returned to the provider for amendment.
Invoices are to be submitted within four weeks of service. Invoices received more than six months after date of service
may not be paid unless in exceptional circumstances.
ReturnToWorkSA or their claims agents are unable to pay on ‘account rendered’ or statement invoices. Payment will be
made, where appropriate, on an original invoice or duplicate/copy of the original.
Payment for services, including reports, will not be made in advance.
GST
For all GST-related queries, please contact the Australian Taxation Office or your tax advisor.
Changes to provider details
For changes to provider details, such as ABN, change of address or electronic funds transfer details, please complete the
Provider registration form available on our website. Once completed either email to prov.main@rtwsa.com or fax to
ReturnToWorkSA on (08) 8238 5690. For any queries relating to this form, please contact ReturnToWorkSA
on 13 18 55.
Where payment is outstanding
Please contact the claims agent, ReturnToWorkSA’s EnABLE Unit or self-insured employer if the claim has been
accepted and the payment is outstanding. If the claim has not been accepted, responsibility for payment of accounts
rests with the worker.
Useful contacts
ReturnToWorkSA - Private hospital fee schedule 2015-16
39
Claims agents
All work injury claims (that are not self-insured or serious injury) are managed by Employers Mutual or Gallagher Bassett.
To identify which claims agent is managing a worker’s claim, refer to the ‘Claims agent lookup’ function on our website
at www.rtwsa.com.
Employers Mutual SA
Phone:
Fax:
(08) 8127 1100 or free call 1300 365 105
(08) 8127 1200
Postal address:
GPO Box 2575, Adelaide SA 5001
Online:
www.employersmutualsa.com.au
Gallagher Bassett Services Pty Ltd
Phone:
Fax:
(08) 8177 8450 or free call 1800 664 079
(08) 8177 8451
Postal address:
GPO Box 1772, Adelaide SA 5001
Online:
www.gallagherbassett.com.au
ReturnToWorkSA EnABLE Unit
For claims relating to severe traumatic injuries, please contact this unit directly.
Phone:
Fax:
13 18 55
(08) 8233 2051
Postal address:
GPO Box 2668, Adelaide SA 5001
Self-insured employers
For matters relating to self-insured claims, please contact the employer directly.
Allianz Australia SA Compulsory Third Party (CTP)
For claims relating to motor vehicle crashes that are managed by Allianz Australia SA CTP on behalf of the insurer, the
Motor Accident Commission, please contact them directly.
Phone:
Fax:
1300 137 331
1300 137 431
Postal address:
GPO Box 219, Adelaide SA 5001
Email:
SACTPClaims@allianz.com.au
ReturnToWorkSA - Private hospital fee schedule 2015-16
40
The following free information support services are available:
If you are deaf or have a hearing or speech impairment you can call ReturnToWorkSA through the National Relay Service (NRS):
TTY users can phone 13 36 77 and ask for 13 18 55.
Speak & Listen (speech-to-speech) users can phone 1300 555 727 and ask for 13 18 55.
Internet Relay users connect to NRS on www.relayservice.com and ask for 13 18 55.
For languages other than English call the Interpreting and Translating Centre on 1800 280 203 and ask for an interpreter to call ReturnToWorkSA on 13
18 55. For Braille, audio or e-text call 13 18 55.
ReturnToWorkSA
Enquiries: 13 18 55
400 King William Street, Adelaide SA 5000
info@rtwsa.com
© ReturnToWorkSA 2015