Treatment case
The case of treatment in Germany is a toll-legal definition of the treatment period of patients who are in the field of public health insurance differs from the definition in the private billing. In both fee schedules, the billing of certain services depends on these definitions if the service text contains a corresponding billing provision.
Treatment case for cash patients
A treatment case is defined in accordance with Section 21, Paragraph 1, Federal Medical Insurance Contract (BMV-Ä) as the treatment of the same insured person by the same doctor or psychotherapy practice in a calendar quarter (quarter) at the expense of the same health insurance company. An analogous provision can be found in the federal contract for dentists (BMV-Z) or in the replacement insurance contract for dentists (EKV-Z), which relates to billing according to the assessment standard for dental services (BEMA).
It also says:
A uniform case of treatment also exists if the illness treated first develops into another illness or occurs during treatment or if the insured person, after having not required treatment for a period, occurs within the same calendar quarter because of the same or another illness in the same doctor's office is treated.
In the rare case of a change of health insurer during a treatment case, a new treatment case is established in the new insurance relationship. This does not apply to a merger of two health insurance companies.
Case of illness
The case of illness according to the Uniform Assessment Standard (EBM) is not identical to the case of illness that is used as a diagnosis- related group (DRG) for accounting in the hospital . Services provided are viewed as homogeneous and paid for with a uniform flat rate. The length of stay has no influence on the flat rate. The illness includes the treatment of the same illness within one year.
Permanent establishment case
In terms of fees, a distinction must be made between permanent establishments, which include the treatment of the same insured person in a calendar quarter by one or more doctors from the same (secondary) permanent establishment at the expense of the same health insurance company, regardless of the treating doctor. (Section 21 (1a) BMV-Ä or in Section 25 (1a) EKV)
Doctor case
The medical case comprises the treatment of the same insured person by the same doctor participating in the contract medical care in a calendar quarter at the expense of the same health insurance company, regardless of the company or subsidiary company. (§ 21 Paragraph 1b BMV-Ä or in § 25 Paragraph 1b EKV)
Treatment case in the private medical sector
Definition of the term treatment case
The treatment case is defined in the “General Provisions for Section B” of the Medical Fee Schedule (GOÄ).
"A treatment case for the treatment of the same illness is the period of one month after the first consultation with the doctor."
Differentiating it from a new illness is often difficult, especially when assessing whether it is a complication of the existing illness or a new illness.
The limitation of the advisory and examination services becomes clear in the general provisions of Section B of the GOÄ: “The services according to numbers 1 and / or 5 are, in addition to services according to sections C (from no. 200 GOÄ) to O, only once in the case of treatment Billable. ”The same applies to the billing of private dental services according to the fee schedule for dentists (GOZ).
Calculation of the monthly deadline
When calculating the monthly period, according to Section 188 (2) of the German Civil Code (BGB) in the case of Section 187 (1) of the German Civil Code does not include the day on which treatment begins.
Example: start of treatment on September 8th; Treatment ends at the end of October 8th.
A new treatment case includes services that are provided immediately afterwards from October 9th up to and including November 9th or with an interruption at a later date, for example from October 14th until November 14th. This also applies to consecutive treatment cases of the same disease.
Service restrictions in the fee schedule are always doctor-related. If the patient consults another doctor about the same or a different illness, a new treatment case will be established regardless of the doctor who was contacted first.
Individual evidence
- ↑ a b c National Association of Statutory Health Insurance Physicians, Federal Cover Agreement (download)
- ↑ Federal Shell Contract Dentists ( Memento of the original from June 13, 2016 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 820 kB)
- ^ Cologne commentary on the EBM . Deutscher Ärzteverlag,, ISBN 978-3-7691-3150-5 , p. 32.
- ↑ The new family doctor EBM in brief ( Memento of the original from January 13, 2014 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ A. Pieritz, The Treatment Case , Deutsches Ärzteblatt 103, Issue 15 (April 14, 2006), Page A-1027
- ^ Comment on the fee schedule for doctors (GOÄ) . Deutscher Ärzteverlag,, ISBN 978-3-7691-3075-1 , p. 247.
