Write the clinical note at the time of the encounter

Record in SOAP format: clinical indication, procedure performed, technique, complications, outcome. Do not reconstruct after the fact — retrospective notes carry minimal evidentiary weight in a forensic audit and are the single largest deficiency in the CMS Final Report.

Verify the billed code matches the documented procedure

Cross-reference against the current SAMA Coding Manual and NAPPI/ICD-10 rules. No upcoding. No unjustified unbundling. Global bundle codes always take precedence over component codes. If uncertain, consult a CCISA-accredited coding specialist before submission.

Confirm the prior-authorisation reference number is on the claim file

For elective procedures: no PA reference = no submission. A verbal authorisation without a written reference does not exist from an audit perspective. For emergencies: document the clinical basis and submit retrospective authorisation within 24 hours.

Attach supporting documentation for high-risk codes

Imaging reports, histology results, referring letters, and operative findings notes must be attached to or immediately retrievable from the clinical file. Under Circular 10, high-risk codes require documentation at submission — not merely on request.

Ensure signed informed consent includes codes, fee, and co-payment

Consent forms must specify the proposed procedure codes, your fee, the applicable scheme tariff, and the anticipated patient co-payment. Oral consent without written documentation is not sufficient for elective procedures. Patient complaints about unexpected costs are a primary algorithmic trigger.

Verify ICD-10 diagnostic code accuracy

The diagnostic code must reflect the specific clinical indication documented in the notes. Avoid generic (.9) or unspecified codes. Maximum coding specificity is expected and its absence is a documented deficiency in the Final Report. Modifier codes must be supported by exact start and stop times in the clinical notes.

Review add-on codes and confirm bundle integrity

Every add-on code must have its supporting primary procedure code present in the same claim. Verify that no component parts of a SAMA global or bundle code have been billed as independent line items. Confirm consumables, medicines, and surgical materials are priced against SEP or agreed scheme pricing rules.

Respond to all scheme queries — never ignore correspondence

Acknowledge within 5 business days. Log every query in your central Query Register. Submit structured clinical motivations with full supporting documentation. Escalate any recovery demand above R50,000, or any formal Section 59 notification, to a healthcare attorney before responding. Do not sign any Acknowledgement of Debt under duress — Circular 10 prohibits coercive AOD practices.

Participate in and document peer review every quarter

Hold a formal clinical governance or morbidity/mortality session with colleagues every 90 days. Document: agenda, attendees, cases reviewed, and practice changes adopted. Under Circular 10, evidence of active clinical governance is a material mitigating factor in any investigation. Practices without peer review documentation fare materially worse in forensic outcomes.

An external RCM audit of your billing history identifies and corrects deficiencies before a scheme or CMS investigation does. A documented Revenue Leakage Review and corrective action plan — compiled into a Governance Report — is the single most effective compliance artefact available to a South African private practice. Practices that can demonstrate proactive self-audit consistently achieve materially better outcomes in CMS and scheme engagement. See the full 6-month governance roadmap for practice managers →