By Edwina Cele  ·  LaunchRx Solvere  ·  Private Practice Toolkit — Post 3 of 6

This is one of the most common and most preventable problems in new practices. Not a clinical error. A billing architecture error. And it happens because nobody actually teaches you how medical billing works before you open your doors.

This post covers the foundational mechanics — what the codes are, where they come from, why claims get rejected, and what needs to be in place before your first claim goes out.

The two codes every claim needs

Every claim you submit to a medical scheme requires two things working together: a diagnosis code and a tariff code. Both must be present. Both must correspond. One without the other means a rejection — consistently, not occasionally.

Where the codes come from

ICD-10 codes are issued under a South African licence from the World Health Organisation (WHO) and are mandatory for all health service providers and medical schemes. They are updated periodically and the South African version is maintained by the Department of Health.

For general practitioners and medical specialists, the working reference for tariff codes is the SAMA Medical Doctors’ Coding Manual (MDCM). Maintained by the Medical Coding Division of SAMA, developed in cooperation with medical disciplines, and updated annually — the 2026 electronic MDCM (eMDCM) is now available.

Allied health practitioners — physiotherapists, occupational therapists, and others — work from their own separate coding references published by their respective professional associations. This post focuses on the medical coding pathway.

Why claims get rejected

Rejections are not random. They follow predictable patterns. The most common causes in new practices are:

• ICD-10 code absent — every line item on a claim requires one
• Tariff code absent or incorrect for the discipline
• Diagnosis code does not clinically support the service billed
• Outdated codes used — codes change annually and schemes check against current versions
• Billing software not configured to the correct discipline codes
• Modifier not applied where required by the scheme
• Claim submitted outside the scheme’s submission timeframe

Prescribed Minimum Benefits (PMBs) and why they matter

Prescribed Minimum Benefits are a defined set of conditions that medical schemes are legally required to cover in full, regardless of a member’s plan or benefit status. The list is set by the Council for Medical Schemes (CMS) and covers emergency conditions, 270 defined chronic conditions, and a list of defined benefit conditions.

Why this matters for billing: the ICD-10 code you assign determines whether a condition qualifies as a PMB. If it does, the member cannot be held responsible for the cost — the scheme must pay at cost. If the ICD-10 code is incorrect or insufficiently specific, the PMB status may not be recognised, the claim may be processed against ordinary benefits, and the patient may face unexpected costs.

Understanding which conditions on your patient base are likely to qualify as PMBs — and coding them correctly — is part of running a practice that is both compliant and fair to patients.

What to have in place before your first claim

• Current MDCM access. The 2026 eMDCM is available from SAMA. SAMA members in private practice receive the first licence free. Verify you are working from the current version before you code a single consultation.
• Billing software configured for your discipline. Default software setups are not discipline-specific. Your system must be loaded with the correct codes for your scope of practice before you see your first patient.
• ICD-10 lookup integrated into your workflow. Every consultation requires a diagnosis code. Your system should support ICD-10 lookups at the point of billing — not as a separate manual step.
• Understanding of each scheme’s rate structure. Different schemes pay different rates for the same tariff code. Know what each scheme pays against each code before you set patient expectations about costs.
• Submission timeframes confirmed per scheme. Each scheme has a defined window for claim submission. Claims submitted outside that window may be rejected regardless of clinical and coding accuracy.

Common billing mistakes in new practices

• Submitting claims before billing software is correctly configured
• Using ICD-10 codes that are too broad or not specific enough to support the service billed
• Using outdated MDCM codes from a previous year’s manual
• Not applying modifiers where required by specific schemes
• Assuming all schemes pay the same rate for the same code — they do not
• Not documenting the clinical rationale that supports the ICD-10 and tariff code combination — documentation must support the billing
• Submitting claims outside the scheme’s timeframe and expecting retrospective processing

Final word

Billing is not a back-office function. It is the operational link between the clinical care you deliver and the income your practice receives. When billing architecture is set up correctly before the first patient walks in, claims move cleanly, rejections are the exception rather than the rule, and your cash flow reflects the work you are actually doing.

Get the foundation right first. Everything else follows from there.