Murrumbidgee Primary Health Network Desktop Guide to MBS Item numbers and care coordination services Murrumbidgee Primary Health Network gratefully acknowledges the financial and other support from the Australian Government Department of Health April 2016 Disclaimer: While every effort is made by the Murrumbidgee PHN to ensure that accurate information is disseminated through this medium, Murrumbidgee PHN makes no representation about the content and suitability of this information for any purpose.
CONTENTS Item Numbers Frequently Used Item Numbers 3 After Hours Item Numbers 3 Prolonged Attendance in Treatment of a Critical Condition 8 Individual Allied Health Services 9 Group Allied Health Services for Patients with Type 2 Diabetes 10 GP Multidisciplinary Case Conferences 11 Health Assessments 12 Residential Aged Care Facility Item Numbers 14 Systematic Care Claiming Rules 15 Flow Charts Healthy Kids Check Health Assessment 16 Type 2 Diabetes Risk Evaluation Health Assessment 17 45 49 Year Old Health Assessment 18 75 Years and Older Health Assessment 19 Aboriginal and Torres Strait Islander Health Assessment 20 Hepatitis B Positive Program Enrolment Flowchart 21 Hep B Pathology Item Numbers/Descriptors 22 Domiciliary Medication Management Review (DMMR) 23 Residential Medication Management Review (RMMR) 24 GP Management Plan (GPMP) 25 Team Care Arrangement (TCA) 26 Reviewing a GP Management Plan (GPMP) and/or a Team Care Arrangement (TCA) 27 Mental Health Treatment Plan 28 Review of the Mental Health Treatment Plan 29 Diabetes Annual Cycle of Care Service Incentive Payment (SIP) 30 Asthma Cycle of Care Service Incentive Payment (SIP) 31 MPHN Programs and Services ffcare Coordinated Supplementary Service (CCSS) 32 ffmedical Outreach Indigenous Chronic Disease Program 33 ffaboriginal and Torres Strait Islander Outreach Worker 34 ffparkinson s Support Nurse Program 35 ffmurrumbidgee Osteoporosis Fracture Prevention Service 36 ffmurrumbidgee Osteoarthritis Chronic Care Program 37 ffintegrated Chronic Disease Program 38 ffintegrated Allied Health Services 40 ffrural Health Outreach Fund 41 ffsmoking Cessation Program 42 ffaccess to Allied Psychological Services (ATAPS) 43 ffwagga Applied Psychology Services (WAPS) 44 ffperinatal Depression Initiative 45 ffcarer s Counselling 46 ffmighty Minds 47 ffpartners in Recovery (PIR) 48 ffheadspace 49 ffrefugee Health Patients 50 MLHD Programs and Servics BreastScreen NSW 51 Oral Health 52 Tuberculosis 53 Mental Health and Drug and Alcohol 56 Practice Incentive and Service Incentive Items Regional Providers Contact Details 57 Practice Incentive Payments and Service Incentive Payments Summary 60 2
FREQUENTLY USED ITEM NUMBERS For a comprehensive explanation of each MBS Item number please refer to the Medicare Benefits Schedule website at www.health.gov.au/mbsonline COMMONLY USED ITEM NUMBERS ITEM NAME $ DESCRIPTION / RECOMMENDED FREQUENCY 3 Level A $ 16.95 Brief see MBS for complexity of care requirements 23 Level B $ 37.05 < 20 min see MBS for complexity of care requirements 36 Level C $ 71.70 20 min see MBS for complexity of care requirements 44 Level D $ 105.50 40 min see MBS for complexity of care requirements 10991 Bulk Billing Item $ 10.85 11506 Spirometry $ 20.55 DVA, under 16s and Commonwealth Concession Card holders. Can be claimed concurrently for eligible patients Measurement of respiratory function before and after inhalation of bronchodilator 11700 ECG $ 31.25 Twelve-lead Electrocardiography, tracing and report CHRONIC DISEASE MANAGEMENT ITEM NAME $ DESCRIPTION / RECOMMENDED FREQUENCY 721 GP Management Plan (GPMP) $ 144.25 723 Team Care Arrangement (TCA) $ 114.30 732 729 Review of GP Management Plan and/or Team Care Arrangement GP Contribution to, or Review of, Multidisciplinary Care Plan $ 72.05 $ 70.40 Management plan for patients with a chronic or terminal condition. Minimum claiming period 12 months. Development of Team Care Arrangements for patients with at least one medical condition present for at least six months or is terminal and requires ongoing care from a team including the GP and at least two other health or care providers. Enables referral for five rebated allied health services. Minimum claiming period 12 months. Each service to which item 732 applies may only be claimed once in a three-month period, except where there are exceptional circumstances that necessitate earlier performance of the service to the patient. Contribution to, or review of, a multidisciplinary care plan prepared by another provider (e.g. community, home or allied health providers, specialists), for patients with a chronic or terminal condition and complex needs requiring ongoing care from a team including the GP and at least two other health or care providers. Not residing in a RACF. Not more than once every three months. 731 GP Contribution to, or Review of, Multidisciplinary Care Plan prepared by RACF $ 70.40 A GP contribution at the request of the facility, to a multidisciplinary care plan, or review of a care plan prepared by RACF, for patients with a chronic or terminal condition and complex needs requiring ongoing care from a team including the GP and at least two other Health or care providers. Not more than once every three months. 3
FREQUENTLY USED ITEM NUMBERS Continued COMMONLY USED ITEM NUMBERS ITEM NAME $ DESCRIPTION / RECOMMENDED FREQUENCY 701 Brief Health Assessment $ 59.35 Lasting not more than 30 minutes* 703 Standard Health Assessment $ 137.90 >30 <45 minutes see MBS for complexity of care requirements* 705 Long Health Assessment $ 190.30 707 Prolonged Health Assessment $ 268.80 715 Aboriginal and Torres Strait Islander Health Assessment 45 <60 minutes see MBS for complexity of care requirements* At least 60 minutes or more see MBS for complexity of care requirements* $ 212.25 Not timed* PRACTICE NURSE ITEM NUMBERS AS OF 1 JANUARY 2012 ITEM NAME $ DESCRIPTION / RECOMMENDED FREQUENCY 10984 Telehealth in RACF $ 32.40 10986 10987 Health Assessment - Healthy Kids Check by Nurse Follow Up Health Services for Indigenous people $ 58.20 $ 24.00 10997 Chronic Disease Management $ 12.00 Patient participating in video consult with specialist or consultant physician. Service by a Practice Nurse, Allied Health worker or Aboriginal and Torres Strait Islander health practitioner on behalf of and under supervision of GP Once only health check for children who have received or are receiving the four-year-old immunisation. Cannot be claimed if a health assessment item has been claimed. Follow up services for an Indigenous person who has received a Health Assessment, not an admitted patient of a hospital. Maximum of 10 services per patient, per calendar year Monitoring and support for patients being managed under a GPMP or TCA. Not more than five, per patient, per year MEDICATION MANAGEMENT AND CYCLES OF CARE ITEM NAME $ DESCRIPTION / RECOMMENDED FREQUENCY 900 Domiciliary Medication Management Review (DMMR) or Home Medicine Review (HMR) $ 154.80 Review of medications in collaboration with a pharmacist for patients at risk of medication related misadventure. Once every 12 months* 903 Residential Medication Management Review (RMMR) $ 106.00 For permanent residents of RACF who are at risk of medication related misadventure. Performed in collaboration with the resident s pharmacist. Once every 12 months* 2521 Diabetes Annual Cycle of Care Level C + SIP $ 71.70 +40 = 111.70 For accredited practices. Used in place of usual attendance item when completing Diabetes Annual Cycle of Care. Once every 11 13 months* 2552 Asthma Cycle of Care Level C + SIP $ 71.70 +100 = 171.70 For accredited practices. Used in place of usual attendance item when completing the Asthma Cycle of Care for patients with moderate to severe asthma. Not more than once a year* * See flow charts in this guide for further information 4
FREQUENTLY USED ITEM NUMBERS Continued MENTAL HEALTH ITEM NUMBERS ITEM NAME $ DESCRIPTION / RECOMMENDED FREQUENCY 2700 GP Mental Health Treatment Plan $ 71.70 Min 20 minutes Prepared by GP who has not undertaken Mental Health Skills Training. Assessment of patient and preparation of a care plan with option to refer for rebated psychological services. Not more than once a year 2701 GP Mental Health Treatment Plan $ 105.55 Min 40 minutes Prepared by GP who has not undertaken Mental Health Skills Training. Assessment of patient and preparation of a care plan with option to refer for rebated psychological services. Not more than once a year 2715 GP Mental Health Treatment Plan $ 91.05 Min 20 minutes - Prepared by GP who has undertaken Mental Health Skills Training. Assessment of patient and preparation of a care plan with option to refer for rebated psychological services. Not more than once a year 2717 GP Mental Health Treatment Plan $ 134.10 Min 40 minutes - Prepared by GP who has undertaken Mental Health Skills Training. Assessment of patient and preparation of a care plan with option to refer for rebated psychological services. Not more than once a year 2712 Review of GP Mental Health Treatment Plan $ 71.70 Plan should be reviewed between one to six months and no more than two per year (claim frequency in relation to other items) 2713 Mental Health Consultation $ 71.70 Consultation 20 minutes For the ongoing management of a patient in relation to a mental disorder. No restriction on the number of these consultations per year 2721 GP Focussed Psychological Strategies $ 92.75 Consultation between 30-40 minutes Provision of focussed psychological strategies by an appropriately trained and registered GP, up to 10 per calendar year. 2725 GP Focussed Psychological Strategies $ 132.75 Consultation for 40 minutes Provision of focussed psychological strategies by an appropriately trained and registered GP, up to 10 per calendar year. Eligibility for provision of focussed psychological strategies by an appropriately trained and registered GP, as determined by the General Practice Mental Health Standards Collaboration (GPMHSC). http://www.racgp.org.au/education/gpmhsc/gps/fps/ 5
AFTER HOURS ITEM NUMBERS To access MBS item numbers online http://www.mbsonline.gov.au/ Non-Urgent After Hours Attendances in Consulting Rooms (Items 5000, 5020, 5040, 5060, 5200, 5203, 5207 and 5208) are to be used for non-urgent consultations at consulting rooms initiated either on a public holiday, on a Sunday, before 8am and after 1pm on a Saturday, or before 8am and after 8pm on any other day. Non-Urgent After Hours Attendances at a place other than Consulting Rooms (other than a Hospital or Residential Aged Care Facility) (items 5003, 5023, 5043, 5063, 5220, 5223, 5227 and 5228) and Non- Urgent After Hours Attendances in a Residential Aged Care Facility (Items 5010, 5028, 5049, 5067, 5260, 5263, 5265 and 5267) are to be used for non-urgent attendances on one or more patients on one occasion on a public holiday, on a Sunday, before 8am and after 12 noon on a Saturday, or before 8am and after 6pm on any other day. Urgent Attendance After Hours These items can only be used for the first patient, if more than one patient is seen on the one occasion. For the second and subsequent patients attending on the same occasion, standard (non-urgent) afterhours items apply. The urgent after-hours items can only be used where the patient has a medical condition that requires urgent treatment, which could not be delayed until the next in-hours period. For times and days these items apply, see table below: ATTENDANCE PERIOD LOCATION APPLICABLE TIME MONDAY TO FRIDAY SATURDAY SUNDAY OR PUBLIC HOLIDAY ITEMS Urgent after hours attendance Return to and specifically open consulting room or attend a place other than consulting rooms Between 7am 8am and 6pm 11pm Between 7am 8am and 12 noon 11pm Between 7am 11pm 597, 598 Urgent after hours in unsociable hours Return to and specifically open consulting room or attend a place other than consulting rooms Between 11pm 7am Between 11pm 7am Between 11pm 7am 599, 600 Non-urgent after hours In consulting rooms Consulting rooms Before 8am or after 8pm Before 8am or after 1pm 24 hours 5000, 5020 5040, 5060 5200, 5203, 5207, 5208 Non-urgent after hours at a place other than consulting rooms Patient s home Before 8am or after 6pm Before 8am or after 12 noon 24 hours 5003, 5023, 5043, 5063, 5220, 5523, 5227, 5228 Non-urgent after hours in an RACF RACF Before 8am or after 6pm Before 8am or after 12 noon 24 hours 5010, 5028, 5049, 5067, 5260, 5263, 5265, 5267 6
AFTER HOURS ITEM NUMBERS Continued The following table lists the MBS benefits for After Hours Home Visits. Amounts are per patient. NO OF PATIENTS AFTER HOURS HOME VISITS GROUP A1 LEVEL A ITEM 5003 LEVEL B ITEM 5023 LEVEL C ITEM 5043 LEVEL D ITEM 5063 AFTER HOURS HOME VISITS GROUP A2 BRIEF ITEM 5220 STD ITEM 5223 LONG ITEM 5227 PRO- LONGED ITEM 5228 ONE $54.95 $74.95 $109.90 $143.70 $34.00 $43.50 $61.00 $83.00 TWO $41.95 $61.95 $96.90 $130.70 $26.25 $34.75 $53.25 $75.25 THREE $37.65 $57.65 $92.60 $126.40 $23.65 $31.85 $50.65 $72.65 FOUR $35.50 $55.50 $90.45 $124.25 $22.35 $30.35 $49.35 $71.35 FIVE $34.20 $54.20 $89.15 $122.95 $21.60 $29.50 $48.60 $70.60 SIX $33.30 $53.30 $88.25 $122.05 $21.10 $28.90 $48.10 $70.10 SEVEN + $31.00 $51.00 $85.95 $119.75 $19.20 $26.70 $46.20 $68.20 The following table lists the MBS benefits for After Hours RACF visits NO OF PATIENTS AFTER HOURS RACF VISITS GROUP A1 LEVEL A ITEM 5010 LEVEL B ITEM 5028 LEVEL C ITEM 5049 LEVEL D ITEM 5067 AFTER HOURS RACF VISITS GROUP A2 BRIEF ITEM 5260 STD ITEM 5263 LONG ITEM 5265 PRO- LONGED ITEM 5267 ONE $75.70 $95.70 $130.65 $164.45 $46.45 $57.55 $73.45 $95.45 TWO $52.35 $72.35 $107.30 $141.10 $32.45 $41.75 $59.45 $81.45 THREE $44.55 $64.55 $99.50 $133.30 $27.80 $36.50 $54.80 $76.80 FOUR $40.65 $60.65 $95.60 $129.40 $25.50 $33.90 $52.50 $74.50 FIVE $38.35 $58.35 $93.30 $127.10 $24.10 $32.30 $51.10 $73.10 SIX $36.80 $56.80 $91.75 $125.55 $23.15 $31.25 $50.15 $72.15 SEVEN + $32.30 $52.30 $87.25 $121.05 $19.75 $27.25 $46.75 $68.75 Group A1 - Vocationally Registered Group A2 - Non-Vocationally Registered All MBS items and rates are effective as of 1 December 2014 Level A - D - as per usual time and complexity requirements - see page 3. Brief < 5 minute Standard 6-25 minutes Long 26-45 minutes Prolonged > 45 minutes 7
PROLONGED ATTENDANCE IN TREATMENT OF A CRITICAL CONDITION These items can be claimed at any time of the day and any day of the week. The patient must be in imminent danger of death One or more medical practitioners can claim these items for simultaneous attendance on one patient and The time spent by the practitioner does not have to be continuous. ITEM ITEM DESCRIPTION TIME MBS BENEFIT 160 CRITICAL CONDITION, prolonged attendance in treatment of 1 - < 2 Hours $221.50 161 CRITICAL CONDITION, prolonged attendance in treatment of 2 - < 3 Hours $369.15 162 CRITICAL CONDITION, prolonged attendance in treatment of 3 - < 4 Hours $516.65 163 CRITICAL CONDITION, prolonged attendance in treatment of 4 - < 5 Hours $664.55 164 CRITICAL CONDITION, prolonged attendance in treatment of 5+ Hours $738.40 8
INDIVIDUAL ALLIED HEALTH SERVICES Allied Health Services for Chronic Conditions Requiring Multidisciplinary Team Care To access Medicare benefits for the following services, GPs must have completed a GP Management Plan (721) and Team Care Arrangement (723) or contributed to a Multidisciplinary Care Plan in a Residential Aged Care Facility (731) and the allied health service must be recommended in the patient s plan as part of the management of their chronic condition. It is not appropriate for AHPs to reverse refer to GPs, or pre-empt the GPs decision about the services required. ITEM NAME $ DESCRIPTION / RECOMMENDED FREQUENCY 10950 Aboriginal Health Worker Services 10951 Diabetes Educator Services 10952 Audiologist Services 10953 Exercise Physiologist Services 10954 Dietitian Services 10958 Occupational Therapist Services 10960 Physiotherapist Services 10962 Podiatrist Services 10964 Chiropractor Services 10966 Osteopath Services 10970 Speech Pathologist Services $62.25 Maximum five allied health services per calendar year Can be five sessions with one provider or a combination e.g. Three dietitian and two diabetes education sessions Separate referral form required for each provider/service type. Referral should state the number of services required by that provider. Allied Health Provider must be Medicare registered Allied Health Provider must supply written report to referring medical practitioner after the first and last service provided. http://www.medicareaustralia.gov.au/provider/ business/audits/files/9090-1207.pdf http://www.medicareaustralia.gov.au/provider/ business/audits/files/9094-1207.pdf http://www.medicareaustralia.gov.au/provider/ business/audits/files/9093-1207.pdf 10956 10968 Mental Health Services Psychologist Services $62.25 Use Better Access Mental Health Care items for mental health conditions (GP Mental Health Treatment Items 2700 2717) for referral to 10 allied health sessions and GPMP and TCA for chronic medical conditions - five sessions Aboriginal & Torres Strait Islander Patients Patients that have identified as Aboriginal and Torres Strait Islander and have undertaken the Item 715 Health Assessment can also be referred for Allied Health follow-up if required. Refer to MBS primary care items 81300 to 81360 Allied Health Service. This is in addition to the services available under individual allied health services, therefore they may access up to 10 sessions per calendar year. Out of pocket expenses: Allied health providers can determine their own fees for the services provided. Charges in excess of the Medicare benefit are the responsibility of the patient and should be discussed with them prior to referral. Patients cannot use private health insurance ancillary cover to pay for out of pocket expenses. 9
GROUP ALLIED HEALTH SERVICES FOR PATIENTS WITH TYPE 2 DIABETES For a comprehensive explanation of each MBS Item number please refer to the Medicare Benefits Schedule online at www.health.gov.au/mbsonline Assessment and Provision of Group Services GP must have completed a GP Management Plan (721), or reviewed an existing GPMP (732), or contributed to, or reviewed, a Multidisciplinary Care Plan in a Residential Aged Care Facility (731). There is no additional requirement for a Team Care Arrangement (723). Once referred, a patient will receive one individual assessment by one of the required providers, after which they may receive up to eight group services per calendar year. These services are available in addition to the five individual allied health services claimable. ITEM NAME $ DESCRIPTION / RECOMMENDED FREQUENCY 81100 81110 81120 Assessment for Group Services by Diabetes Educator Assessment for Group Services by Exercise Physiologist Assessment for Group Services by Dietitian $79.85 One assessment session only by either Diabetes Educator, Exercise Physiologist or Dietitian, per calendar year Use of Medicare Allied Health Group Services for Type 2 Diabetes Referral Form recommended. 81105 81115 Diabetes Education Group Services Exercise Physiologist Group services $19.90 Eight group services per calendar year, can be eight sessions with one provider or a combination e.g. three diabetes education, three dietitian and two exercise physiology sessions. Use of Medicare Allied Health Group Services for Type 2 Diabetes Referral Form recommended. Groups must comprise between 2-12 participants. Sessions must be at least 60 minutes. 81125 Dietetics Group services Allied health provider must provide a report to the referring practitioner after the initial assessment and upon completion of the group program. Medicare rebates and private health insurance rebates cannot both be claimed for this service. 10
GP MULTIDISCIPLINARY CASE CONFERENCES For patients in the community, RACF or private in-patient hospital discharge. At least 2 other care or service providers must take part. ITEM NAME COSTS TIME 735 Organise and coordinate a case conference $70.65 739 Organise and coordinate a case conference $120.95 743 Organise and coordinate a case conference $201.65 747 Participate in a case conference $51.90 750 Participate in a case conference $89.00 758 Participate in a case conference $148.20 15 19 minutes. GP organises and coordinates case conference in RACF or community or on discharge. For patients with a chronic or terminal condition and complex, multidisciplinary care needs 20 39 minutes. GP organises and coordinates case conference in RACF or community or on discharge. For patients with a chronic or terminal condition and complex, multidisciplinary care needs 40+ minutes. GP organises and coordinates case conference in RACF or community or on discharge. For patients with a chronic or terminal condition and complex, multidisciplinary care needs 15 19 minutes. GP participates in a case conference in RACF or community or on discharge. For patients with a chronic or terminal condition and complex, multidisciplinary care needs 20 39 minutes. GP participates in a case conference in RACF or community or on discharge. For patients with a chronic or terminal condition complex, and multidisciplinary care needs 40+ minutes, GP participates in a case conference in RACF or community or on discharge. For patients with a chronic or terminal condition and complex, multidisciplinary care needs The team case conference should: Discuss patient history Identify multidisciplinary care needs Identify outcomes to be achieved by all members Identify tasks required to achieve these outcomes and assign them to team members Assess if previously identified outcomes were achieved (if relevant). REGULATORY REQUIREMENTS To organise and coordinate case conference items 735, 739 and 743, the provider must: (a) explain to the patient the nature of a multidisciplinary case conference, and ask the patient for their agreement to the conference taking place; and (b) record the patient s agreement to the conference; and (c) record the day on which the conference was held, and the times at which the conference started and ended; and (d) record the names of the participants; and (e) offer the patient and the patient s carer (if any, and if the practitioner considers it appropriate and the patient agrees) a summary of the conference and provide this summary to other team members; and (f) discuss the outcomes of the conference with the patient and the patient s carer (if any, and if the practitioner considers it appropriate and the patient agrees); and (g) record all matters discussed and identified by the case conferencing team and put a copy of that record in the patient s medical records. To participate in multidisciplinary case conference items 747, 750 and 758, the provider must: (a) explain to the patient the nature of a multidisciplinary case conference, and ask the patient whether they agree to the medical practitioner s participation in the conference; and (b) record the patient s agreement to the medical practitioner s participation; and (c) record the day on which the conference was held, and the times at which the conference started and ended; and (d) record the names of the participants; and (e) record all matters discussed and identified by the case conferencing team and put a copy of that record in the patient s medical records. 11
HEALTH ASSESSMENTS For a comprehensive explanation of each MBS Item number please refer to the Medicare Benefits Schedule online at www.health.gov.au/mbsonline Health Assessments should be provided by patient s usual doctor. Primary Care Nurses may assist with performing the assessment. ITEM NAME DESCRIPTION / RECOMMENDED FREQUENCY Up to 30mins a) Collection of relevant information, including taking a patient history; b) A basic physical examination; c) Initiating interventions and referrals as indicated; and d) Providing the patient with preventive health care advice and information. 701 Brief Health Assessment $59.35 Incorporating: Health Assessment Healthy Kids Check Once only health check, by GP, for children who have received or are receiving the 4 year old immunisation Health Assessment Type 2 Diabetes Risk Evaluation Provision of lifestyle modification advice and interventions for patients aged 40-49 years who score 12 on AUSDRISK. Once every three years Health Assessment 45 49 Year Old Once only health assessment for patients 45-49 years who are at risk of developing a chronic disease Health Assessment 75 Years and Older Health assessment for patients aged 75 years and older. Once every 12 months Health Assessment Comprehensive Medical Assessment Medical Assessment for permanent residents of RACF. Available for new and existing residents. Not more than once yearly Health Assessment for patient with an Intellectual Disability Health assessment for patient with an Intellectual Disability. Not more than once yearly Health Assessment for Refugees and other Humanitarian Entrants Once only health assessment for new refugees and other humanitarian Former serving members of the Australian Defense Force including former members of permanent and reserve forces Once only health assessment 703 Standard Health Assessment $137.90 >30 - <45 mins a) Detailed information collection, including taking a patient history; b) An extensive physical examination; c) Initiating interventions and referrals as indicated; and d) Providing a preventive health care strategy for the patient. 12
HEALTH ASSESSMENTS Continued ITEM NAME DESCRIPTION / RECOMMENDED FREQUENCY 705 Long Health Assessment $190.30 45 <60 minutes a) Comprehensive information collection, including taking a patient history; b) An extensive examination of the patient s medical condition and physical function; c) Initiating interventions and referrals as indicated; and d) Providing a basic preventive health care management plan for the patient. Incorporating the Health Assessment categories listed in 701 707 Prolonged Health Assessment $268.80 60 minutes or more a) Comprehensive information collection, including taking a patient history; b) An extensive examination of the patient s medical condition, and physical, psychological and social function. c) Initiating interventions and referrals as indicated; and d) Providing a comprehensive preventive health care management plan for the patient. Incorporating the Health Assessment categories listed in 701 715 Aboriginal and Torres Strait Islander Peoples Health Assessment $212.25 No designated time or complexity requirements Incorporating: ABORIGINAL AND TORRES STRAIT ISLANDER Child Health Assessment Health Assessment for ABORIGINAL AND TORRES STRAIT ISLANDER patients 0 14 years old. Not available to in-patients of a hospital or RACF. Not more than once every nine months ABORIGINAL AND TORRES STRAIT ISLANDER Adult Health Assessment Health Assessment for ABORIGINAL AND TORRES STRAIT ISLANDER patients 15 54 years old. Not available to in-patients of a hospital or RACF. Not more than once every nine months ABORIGINAL AND TORRES STRAIT ISLANDER Health Assessment for an Older Person Health Assessment for ABORIGINAL AND TORRES STRAIT ISLANDER patients 55 years and over. Not available to in-patients of a hospital or RACF. Not more than once every nine months 10986 Health Assessment - Healthy Kids Check by Nurse $58.20 Once only health check for children who have received or are receiving the four-year-old immunisation Only if patient has not already received a Healthy Kid s Check under items 701-707 13
RESIDENTIAL AGED CARE FACILITY ITEM NUMBERS ITEM NAME DESCRIPTION / RECOMMENDED FREQUENCY < 30 minutes - see MBS for complexity of care requirements Incorporating: 701 Brief Health Assessment 703 Standard Health Assessment 705 Long Health Assessment 707 Prolonged Health Assessment Health Assessment - Comprehensive Medical Assessment Comprehensive Medical Assessment (CMA) for permanent residents of Residential Aged Care Facilities. Available for new and existing residents. Not more than one yearly. 30-44 minutes - see MBS for complexity of care requirements. Incorporating: Health Assessment - CMA 45-60 minutes - see MBS for complexity of care requirements. Incorporating: Health Assessment - CMA > 60 minutes - see MBS for complexity of care requirements. Incorporating: Health Assessment - CMA CMA Activities: Time based, see MBS for complexity of care requirements for each items. CMA requires assessment of the resident s health and physical and psychological function, and must include: Obtaining and record resident s consent Information collection, including taking patient history and undertaking or arranging examinations and investigations as required Making an overall assessment of the patient Recommending appropriate interventions Providing advice and information to the patient Keeping a record of the Health Assessment - CMA, and offering the patient a written report about the health assessment, with recommendations about matters covered by the Health Assessment - CMA Providing a written summary of the outcomes of the Health Assessment - CMA for the resident s records and to inform the provision of care for the resident by the RACF, and assist in the provision of Medication Management Review services for the resident. ITEM NAME DESCRIPTION / RECOMMENDED FREQUENCY 731 GP Contribution to, or Review of, Multidisciplinary Care Plan prepared by RACF A GP contribution at the request of the facility, to a multidisciplinary care plan, or review of a care plan prepared by RACF, for patients with a chronic or terminal condition and complex needs requiring ongoing care from a team including the GP and at least two other Health or care providers. Not more than once every three months. Activites: Obtain and record resident s consent Prepare part of the plan or amendments to the plan and add a copy to the patient s medical records; or give advice to a person (e.g. Nursing staff in RACF) who prepares or reviews the plan and records in writing, on the patient s medical records, any advice provided. 14
SYSTEMATIC CARE CLAIMING RULES For a comprehensive explanation of each MBS Item number please refer to the Medicare Benefits Schedule online at www.health.gov.au/mbsonline No Claiming Restrictions 2546 Asthma Cycle of Care SIP 721 GP Management Plan (GPMP) 2700 / 2701 GP Mental Health Treatment Plan 723 Team Care Arrangement (TCA) 2712 Review of GP Mental Health Treatment Plan 732 Review of GPMP and/or TCA 2713 GP Mental Health Consultation 900 Home Medication Review 2715 / 2717 GP Mental Health Treatment Plan Months until Next Claim for Service 2517 Diabetes Cycle of Care 3/6/12 3/6/12 Month Claiming restrictions MBS ITEM NUMBERS *721 *723 **732 900 2517 2546 2700 / 2701 2712 2713 2715/ 2717 *721 12 6 12 *723 12 6 **732 6 6 6 3 3 900 12 2517 3 11 13 2546 12 3 12 2700/2701 12 3 2712 3 3 3 2713 AS REQUIRED 2715/2717 12 Additional Claiming Rules *721 & 723 Recommended claiming period, minimum period 12 months except where exceptional circumstances require preparation of a new GPMP **732 Each service to which item 732 applies may only be claimed once in a three-month period, except where there are exceptional circumstances that necessitate earlier performance of the service to the patient 2517 Recommended not to be claimed within 3 months of Review Item 732, as services overlap 2546 Recommended not to be claimed within 12 months of claiming Item 721 alone, as services significantly overlap. Can be claimed on the same day if both 721 and 723 are completed, as the patient has multidisciplinary care needs. Recommended not to be claimed within 3 months of Review Item 732, as services overlap 2713 This item number can be billed within a GPMHTP or as a stand-alone consultation as many times as required 2712 Review recommended one to six months after 2700, 2701, 2715, 2717, with not more than two reviews in a 12 month period Notes: Where a service is provided earlier than minimum claiming periods the patient invoice and Medicare claim should be annotated. For example; clinically indicated/required, hospital discharge, exceptional circumstances, significant change. Standard consultations, health assessments, treatment plans and medication reviews should not be claimed on the same day. If provided on the same day the patient invoice and Medicare claim should be annotated, for example; clinically indicated/required, separate service. 15
HEALTHY KIDS CHECK HEALTH ASSESSMENT ITEMS 701/703/705/707 Ensure eligibility & obtain patient consent Children between three to five-years-old Children who have not previously had a health assessment (including 10986) Children who are receiving or have received their four-year-old immunisation Perform Health Check Document Relevant Information Clinical Content Explain Health Assessment process and gain parent s/carer s consent Information collection - take patient history and undertake, or arrange examinations and investigations as required Physical examinations and assessments must include: Height and Weight (plot and interpret growth curve/calculate BMI); Eyesight; Hearing; Oral health (teeth and gums); Toileting; and Allergies Discuss: eating habits; physical activity; speech and language development; fine and gross motor skills; behaviour and mood Other examinations considered necessary by GP/Practice Nurse Make an overall assessment of the patient Recommend appropriate interventions Provide advice and information Essential Documentation Requirements Record parent s/carer s consent to Health Assessment Record that 4-year-old immunisation was given Record the Health Assessment and offer the parent/carer a copy Update parent-held child health record Identify health concerns & arrange referrals Claiming All elements of the service must be completed to claim 701/703/705/707 (GP) or 10986 (PN). Claim MBS Item MBS ITEM NAME AGE RANGE RECOMMENDED FREQUENCY 701/703/705/707 10986 Health Assessment Healthy Kids Check by GP Health Assessment Healthy Kids Check by PN or registered Aboriginal Health Worker 3 5 years Once Only 3 5 years Once Only 16
TYPE 2 DIABETES RISK EVALUATION HEALTH ASSESSMENT ITEMS 701/703/705/707 Perform records search to identify at risk patients and actively recall Patients aged 40 to 49 years inclusive Patients must score 12 points (high risk) on Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) Not for patients in hospital Not for patients with newly diagnosed or existing diabetes. Perform AUSDRISK Within 3 months Clinical Content Explain Health Assessment process and gain consent Evaluate the patient s risk score determined by the AUSDRISK, which has been completed within a period of three months prior to undertaking the health assessment Update patient history and undertake physical examinations and clinical investigations in accordance with relevant guidelines Make an overall assessment of the patient s risk factors, and results of relevant examinations and investigations Initiate interventions where appropriate, including referral to relevant allied health and/or lifestyle modification or health coaching programs and follow-up Provide advice and information including strategies to achieve lifestyle and behaviour changes Perform Health Check Nurse may collect information GP must see patient Essential Documentation Requirements Record patient s consent to Health Assessment Completion of AUSDRISK is mandatory, with a score of 12 points required to claim; Update patient history Record the Health Assessment and offer the patient a copy Claiming All elements of the service must be completed to claim Requires personal attendance by GP with patient Claim MBS Item MBS ITEM NAME AGE RANGE RECOMMENDED FREQUENCY 701/703/705/707 Health Assessment Type 2 Diabetes Risk Evaluation 40 49 years Once every 3 years 17
45 49 YEAR OLD HEALTH ASSESSMENT ITEMS 701/703/705/707 Perform records search to identify at risk patients and actively recall Perform Health Check Nurse may collect information GP must see patient Patients aged 45 to 49 years inclusive Must have an identified risk factor for chronic disease Not for patients in a hospital Risk Factors Include, but are not limited to: Lifestyle: smoking; physical inactivity; poor nutrition; Alcohol use Biomedical: high cholesterol; high BP; impaired glucose metabolism; excess weight Family history of chronic disease Mandatory Content Explain Health Assessment process and gain consent Information collection take patient history; undertake examinations and investigations as clinically required Overall assessment of the patient s health, including their readiness to make lifestyle changes Initiate interventions and referrals as clinically indicated Advice and information about lifestyle modification programs and strategies to achieve lifestyle and behaviour changes Arrange referrals as required Essential Documentation Requirements Record patient s consent to Health Assessment Record the Health Assessment and offer the patient a copy Claiming All elements of the service must be completed to claim Claim MBS Item MBS ITEM NAME AGE RANGE RECOMMENDED FREQUENCY 701/703/705/707 Health Assessment 45-49 Year Old 40 49 years Once only 18
75 YEARS AND OLDER HEALTH ASSESSMENT ITEMS 701/703/705/707 Perform records search to identify at risk patients and actively recall Perform Health Assessment Nurse may collect information GP must see patient Complete Documentation Patients aged 75 years and older Patient seen in consulting rooms and/or at home Not for patients in hospital or a Residential Aged Care Facility Mandatory Content Explain Health Assessment process and gain patient s/ carer s consent Information collection take patient history; undertake examinations and investigations as clinically required Measurement of: BP, Pulse rate and rhythm Assessment of: Medication; Continence; Immunisation status for influenza, tetanus and pneumococcus; Physical function including activities of daily living and falls in the last three months; Psychological function including cognition and mood; and Social function including availability and adequacy of paid and unpaid help and the patient s carer responsibilities Overall assessment of patient Recommend appropriate interventions Provide advice and information Discuss outcomes of the assessment and any recommendations with patient Non-Mandatory: Consider: Need for community support services; Social isolation; Oral health and dentition; and Nutrition status Additional matters as relevant to the patient Essential Documentation Requirements Record patient s/carer s consent to Health Assessment Record the Health Assessment and offer the patient a copy (with consent, offer to carer) Claiming All elements of the service must be completed to claim Claim MBS Item MBS ITEM NAME AGE RANGE RECOMMENDED FREQUENCY 701/703/705/707 Health Assessment 75 Years and Older 75 years and older Once every 12 months 19
ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH ASSESSMENT ITEM 715 GP performs Health Assessment 715 Claim MBS Item 715 Referral to Allied Health Service if required Allied Health Service Must be of a least 20 minutes duration Service must be performed personally by Allied Health Professional Eligibility Aboriginal or Torres Strait Islanders of any age Not for hospital inpatients or RACF residents Mandatory Content Patient must identify as Aboriginal and/or Torres Strait Islander Health Assessment includes physical, psychological and social wellbeing. It also assesses what preventative health care, education and other assistance that should be offered to improve the patient s health and wellbeing. It must include: Information collection of patient history and undertaking examinations and investigations as required. For more detail see notes A34, A35 and A36 of the MBS Overall assessment of the patient; Recommending appropriate interventions Providing advice and information to the patient Recording the health assessment; and Offering the patient and/or carer a written report with recommendations about matters covered by the health assessment Referral to Allied Health Services Item 715 Health Assessment must be in place before referral to Allied Health (Items 81300 to 81360 or 10950 to 10970) if required. Items 81300 to 81360 are in addition to Items 10950 to 10970 and provide an alternative to the referral pathway to access Allied Health Services, allowing up to 10 allied health services per calendar year. Items available to individual patients only, not as a group service. Allied health professionals may set their own fees. Charges in excess of the Medicare benefit for these items are the responsibility of the patient. Allied Health must provide written report to GP MBS ITEM NAME AGE RANGE RECOMMENDED FREQUENCY 715 Aboriginal and Torres Strait Islander Health Assessment All ages Once in a nine month period 81300 to 81360 Allied Health Services All ages Max five services per year 10987 Service provided by Practice Nurse or registered Aboriginal Health Worker All ages Max ten services per year 10950 to 10970 Allied Health referral (chronic disease) All ages Max five services per year 20
HEPATITIS B POSITIVE PROGRAM ENROLMENT FLOWCHART Check Patient Eligibility and Recall Search high risk population and create register: Males / female age > 35 years Family history of Liver Cancer (NB: Asian-born residents from high HBV endemic areas (e.g. China, Hong Kong, Vietnam, Cambodia) and other migrant residents diagnosed with Chronic Hepatitis B (CHB)) Generate recall letter or contact patients to make appointment Discuss lifestyle/family/patient history. Generate pathology tests: HBsAg (Hep B Surface Antigen) HBeAg (Marker of HBV infectivity) HBV DNA (Viral load) ALT Arrange follow up appointment (1-2 weeks) to review results. Arrange appropriate tests Review results: if the blood test HBsAg is positive, then patient is eligible for Cancer Council Hep B Positive Program. GP to complete Enrolment Case Record Form. Enrolment to Program Generates $25 If result is negative, set recall in software for six months review consultation and pathology tests. Follow Up Appointment to Discuss Results and Enrolment Please refer to Hep B program enrolment pack for guidance on tests and management. MBS ITEM NUMBER 23, 36 (or 721 can be claimed if patient has GPMP or 723 if Hep B positive and patient presents with another chronic co-morbidity e.g. Diabetes, respiratory etc.) Follow up Review of Hep B Program Enrolled Patients Generates $25. Recommended every six months. 21
HEP B PATHOLOGY ITEM NUMBERS/DESCRIPTORS Item 69482: Quantitation of Hepatitis B viral DNA in patients who are Hepatitis B surface antigen positive and have chronic hepatitis B, but are not receiving antiviral therapy 1 test Applicable no more than once yearly. Bulk Billing Fee: $152.10 Item 69483: Quantitation of Hepatitis B viral DNA in patients who are Hepatitis B surface antigen positive and who have chronic hepatitis B and are receiving antiviral therapy 1 test Applicable not more than 4 times in a 12 month period. Bulk Billing Fee: $152.10 Item 69475: One test for hepatitis antigen or antibodies to determine immune status or viral carriage following exposure or vaccination to Hepatitis A, Hepatitis B, Hepatitis C or Hepatitis D Bulk Billing Fee: $15.65 Item 69478: 2 tests described in 69475 Bulk Billing Fee: $29.25 Item 69481: Investigation of infectious causes of acute or chronic hepatitis 3 tests for hepatitis antibodies or antigens. Bulk Billing Fee: $40.55 Items 69475, 69478, 69481: Only one of these 3 items can be claimed per patient encounter. Item 66500: Quantitation in serum, plasma, urine or other body fluid (except amniotic fluid), by any method except reagent tablet or reagent strip (with or without reflectance meter) of: acid phosphatase, alanine aminotransferase, albumin, alkaline phosphatase, ammonia, amylase, aspartate aminotransferase, bicarbonate, bilirubin (total), bilirubin (any fractions), C-reactive protein, calcium (total or corrected for albumin), chloride, creatine kinase, creatinine, gamma glutamyl transferase, globulin, glucose, lactate dehydrogenase, lipase, magnesium, phosphate, potassium, sodium, total protein, total cholesterol, triglycerides, urate or urea 1 test. Bulk Billing Fee: $9.70 66512: 5 or more tests described in item 66500. Bulk Billing Fee: $17.70 22
DOMICILIARY MEDICATION MANAGEMENT REVIEW (DMMR) ITEM 900 Also known as Home Medicines Review (HMR) Ensure Patient Eligibility Patients at risk of medication related problems or for whom quality use of medicines may be an issue Not for patients in a hospital or RACF Should be performed by patient s usual GP First GP Visit Discussion and referral to pharmacist Initial Visit with GP Explain purpose, possible outcomes, process, and information sharing with pharmacist and possible out of pocket costs Gain and record patient s consent to DMMR Assess patient s medication management needs Inform patient of need to return for second visit Complete DMMR referral and send to patient s preferred pharmacy or accredited pharmacist HMR Interview Conducted by accredited pharmacist Second GP Visit Discuss and develop medication management plan DMMR Interview Pharmacist holds review in patient s home unless patient prefers another location Pharmacist prepares a report and sends to the GP covering review findings and suggested medication management strategies Pharmacist and GP discuss findings and suggestions Second GP Visit Discuss summary of findings and develop medication management plan Discuss plan with patient and offer copy of completed plan Send copy of plan to pharmacist Claiming All elements of the service must be completed to claim Requires personal attendance by GP with patient Claim MBS Item Example risk factors known to predispose people to medication related adverse events are: Currently taking five or more regular medications Taking more than 12 doses of medication per day Significant changes made to medication treatment regimen in last 3 months Medication with a narrow therapeutic index or medications requiring therapeutic monitoring Symptoms suggestive of an adverse drug reaction Sub-optimal response to treatment with medicines Suspected non-compliance or inability to manage medication related therapeutic devices Patients having difficulty managing their own medicines because of literacy or language difficulties, dexterity problems or impaired sight, confusion/dementia or other cognitive difficulties Patients attending a number of different doctors, both GPs and specialists Recent discharge from a facility / hospital (in the last four weeks) MBS ITEM NAME RECOMMENDED FREQUENCY 900 Domiciliary Medication Management Review Once every 12 months 23
RESIDENTIAL MEDICATION MANAGEMENT REVIEW (RMMR) ITEM 903 Ensure Patient Eligibility Patients likely to benefit from a review For permanent residents (new or existing) of a RACF (includes veterans) Patients at risk of medication related misadventure or for whom quality use of medicines may be an issue Not for patients in a hospital or respite patients in RACF The potential need for a RMMR can be identified by the GP, reviewing pharmacist, supply pharmacist, RACF staff, the resident, their carers or other members of their healthcare team Collaborate with reviewing pharmacist GP Requirements Explain RMMR process and gain resident s consent Collaborate with reviewing pharmacist Provide input from Comprehensive Medical Assessment or relevant clinical information for RMMR and the resident s records Medication Review By pharmacist Post Review Discussion Face to face or by phone Complete Documentation Accredited Pharmacist Requirements Review resident s clinical notes and interview resident Prepare Medication Review report and send to GP GP and Pharmacist Post Review Discussion Discuss: Findings and recommendations of the Pharmacist; Medication management strategies; issues; implementation; follow up; outcomes If no (or only minor) changes recommended a post review discussion is not mandatory Essential Documentation Requirements Record resident s consent to RMMR Develop and/or revise Medication Management Plan which should identify medication management goals and medication regimen after discussion with pharmacist Finalise Plan after discussion with resident Offer copy of Plan to resident/carer, provide copy for resident s records and for nursing staff at RACF, discuss plan with nursing staff if necessary Claim MBS Item Claiming All elements of the service must be completed to claim Derived fee arrangements do not apply to RMMR MBS ITEM NAME RECOMMENDED FREQUENCY 903 Residential Medication Management Review Once every 12 months unless significant changes occur 24
GP MANAGEMENT PLAN (GPMP) ITEM 721 Ensure Patient Eligibility Develop Plan Nurse may collect information GP must see patient No age restrictions for patients Patients with a chronic or terminal condition Patients who will benefit from a structured approach to their care Not for public patients in a hospital or in an RACF For patients in the community and private patients being discharged from hospital A GP Mental Health Treatment Plan (Item 2700/2701/2715/2717) is suggested for patients with a mental disorder Should be performed by patient s usual GP Clinical Content Explain steps involved in GPMP, possible out of pocket costs, gain consent Assess health care needs, health problems and relevant conditions Agree on management goals with the patient Confirm actions to be taken by the patient Identify treatments and services required Arrangements for providing the treatments and services Review using item 732 at least once over the life of the plan Complete Documentation Essential Documentation Requirements Record patient s consent to GPMP Patient s health problems and relevant conditions, needs and goals, patient actions, and treatments/services required Set review date Offer copy to patient (with consent, offer to carer), keep copy in patient file Claim MBS Item Claiming All elements of the service must be completed to claim Requires personal attendance by GP with patient Review using item 732 at least once during the life of the plan MBS ITEM NAME RECOMMENDED FREQUENCY MINIMUM CLAIMING PERIOD 721 GP Management Plan Two yearly 12 months 25