Circular no. 8 of 2025

1. We issued Circular No. 4 of 2025 that informed healthcare stakeholders that phase 2.1 will be implemented from 01 April 2025 to 30 June 2025 and phase 2.2, the mandatory phase of ICD-10 would be implemented from 01 July 2025.
2. The essence of phase 2.1 is that ,no claims would be rejected by Medical Aid Funds, claims submitted to Medical Aid Funds or provided to members of registered Medical Aid Funds including the Public Service Employee Medical Aid Scheme (PSEMAS) will contain ICD-10 codes selected from the ICD-10 Master Industry Table (MIT), claims from non-diagnosing providers would be submitted with either the referral diagnosis received from the diagnosing provider, an appropriate sign or symptom code, or a relevant code from Chapter XXI (Z codes). Medical Aid Funds Administrators remained required to validate ICD-10 codes on claims against the ICD-10 Master Industry Table for accuracy and correctness; and provide feedback to providers indicating their level of compliance.
3. To meet the above requirements of phase 2.1, all healthcare stakeholders were required to enhance and upgrade their billing and practice management systems as per the ICD-10 Technical User Guide.
4. An analysis of claims data submitted to all registered Medical Aid Funds for the period of 01 January 2025 to 31 March 2025 revealed that 39.22% of claims submitted to Medical Aid Funds contained the required valid 3-character ICD-10 codes that were appropriately selected from the ICD-10 Master Industry Table. Thus, rendering this to be the claims that would have been paid in phase 2.2.

5. The remaining 61% of claims submitted to Medical Aid Funds in one way or another was deficient as per the summarised below key findings:
5.1 40.05% of claim lines were submitted without any ICD-10 codes.
5.2 20.74% of claim lines contained invalid codes, including:
(a) 1- or 2-character codes
(b) ICD-10-CM or CPT codes
(c) Incorrect formatting (e.g., a dot placed after the second character, spaces between characters, use of delimiters, or numeric characters placed incorrectly before or after codes)
6. These challenges were largely attributed to billing systems limitations and general lack of understanding of ICD-10 requirements.
7. Premised on the above findings, the Management Committee of Namaf resolved that:
7.1 the industry is not adequately prepared for the implementation of the mandatory phase (phase 2.2) of ICD-10.
7.2 To ensure readiness of the industry by 01 July 2026, healthcare stakeholders are required to take the following actions:
7.2.1 Practice Management Software (PMS) must support ICD-10 coding at the line-item level, enabling submission of one primary and up to nine secondary codes per line.
7.2.2 PMS vendors must ensure that the ICD-10 field is a forced-filed that only allows capture of ICD-10 codes from the ICD-10 Master Industry Table.
7.2.3 Hospital systems must support ICD-10 coding at the claim header level, allowing for one primary and up to 19 secondary codes.
7.2.4 Administrator systems must accommodate both PMS and hospital formats to ensure interoperability.
7.2.5 Administrator systems must be upgraded to accommodate the new alphanumeric ICD-10 reason and rejection codes.
7.2.6 Switching companies must ensure that their systems support both PMS and hospital formats when transmitting claims.
7.2.7 Healthcare providers are urged to upgrade their billing systems to software that supports ICD-10 functionality.
7.2.8 Providers should participate in ICD-10 training sessions and workshops as scheduled by NAMAF offered free of charge.
8. This circular therefore, serves to inform all healthcare stakeholders that the current ICD-10 Phase 2.1 has been extended and the implementation of Phase 2.2 the mandatory phase – where no ICD-10 code no payment principle applies, originally scheduled for 01 July 2025, has been tentatively deferred to 01 July 2026.