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What is the urgent or emergency surcharge?
Learn when to apply the 30% surcharge on physician fees under the CBHPM. This article explains the rules for night hours, weekends and holidays, as well as how to fill in the TISS standard correctly to avoid denials
- By
- Rivio, Editorial team
- Published
- Reading time
- 2 minutes
The distinction between urgency and emergency relates to the severity of the clinical condition, the immediate threat to life and the possibility of irreversible harm to the patient. While an emergency implies an imminent risk of death, urgency involves situations that require prompt care but without immediate risk.
In care and regulatory practice, however, the terms urgency and emergency are often treated as a single area of care, following the terminology adopted by the Ministry of Health.
CBHPM tier surcharge for urgent and emergency care
According to the Brazilian Hierarchical Classification of Medical Procedures(CBHPM), medical care provided on an urgent or emergency basis is entitled to a 30% surcharge on the procedure’s tier (porte), provided it falls under one of the situations below:
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Care provided between 7 p.m. and 7 a.m. the next day.
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Care provided on Saturdays, Sundays and holidays.
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Care started during regular hours and completed in a period considered urgent or emergency.
Application rule: the 30% surcharge must be applied when more than half of the procedure is performed within the period characterized as urgent or emergency.
A practical example of applying the surcharge
Consider the following scenario:
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Care in the emergency room, started at 11:30 p.m. on 02/02/2018.
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Procedure charged: 10101039 – Emergency Room Care, according to the CBHPM.
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Classification: CBHPM 2016 – Tier 2B.
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Value of tier 2B: R$ 91.65.
In this case, the care took place entirely during the night period, which characterizes it as urgent/emergency. The 30% surcharge on the tier value is therefore allowed:
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Tier value: R$ 91.65
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30% surcharge: R$ 27.49
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Total amount to be charged: R$ 119.14
Watch out for billing in the TISS standard
It is important to note that the urgent/emergency surcharge can and should be reported in the TISS standard, using the “Reduction and Surcharge Factor” field.
If there are questions about filling in this field correctly, it is advisable to consult the current TISS technical manual or the payer’s billing department, in order to avoid denials, contract discrepancies or challenges during the audit process.
