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The Australian Government

Department of Health and Ageing

Medicare Benefits Schedule

Allied Health Services

1 OCTOBER 2013

At the time of printing, the relevant legislation giving authority for the changes included in this edition of the book may still be subject to the usual Parliamentary scrutiny. This book is not a legal document, and, in cases of discrepancy, the legislation will be the source document for payment of Medicare benefits.

Online ISBN: 978-1-74241-881-0

Publications approval number: 10060

Copyright Statement:

Internet sites

© Commonwealth of Australia 2013

This work is copyright. You may download, display, print and reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health and Ageing, GPO Box 9848, Canberra ACT 2601, or via e-mail to copyright@health.gov.au.

Table of Contents

PART 1
INFORMATION FOR ALLIED HEALTH PROVIDERS 7

1.1 ELIGIBLE ALLIED HEALTH PROVIDERS 7

1.2 ELIGIBILITY OF PATIENTS 7

1.3 GENERAL PRACTITIONER (GP) 9

1.4 MULTIPLE CONSULTATIONS ON THE SAME DAY 9

1.5 SERVICE REQUIREMENTS 10

1.6 MEDICARE BENEFIT/REBATE 10

1.7 DIRECT (BULK) BILLING 10

1.8 FEE SETTING AND OUT-OF-POCKET COSTS 10

1.9 MEDICARE SAFETY NET 10

1.10 PUBLICLY FUNDED SERVICES AND 19(2) EXEMPTIONS 10

1.11 PRIVATE HEALTH INSURANCE 11

1.12 CLAIMING FROM MEDICARE 11

1.12.1 Billing practices contrary to the Act 11

1.13 CHANGES TO PROVIDER DETAILS 11

1.14 MEDICARE AUSTRALIA CONTACT DETAILS 12

1.15 DEPARTMENT OF HEALTH AND AGEING CONTACT DETAILS FOR ITEMS IN THIS SCHEDULE 12

PART 2
INDIVIDUAL ALLIED HEALTH SERVICES FOR PATIENTS WHO HAVE A CHRONIC (OR TERMINAL) CONDITION AND COMPLEX CARE NEEDS
(MBS ITEMS 10950 TO 10970) 13

2.1 ELIGIBLE PATIENTS 13

2.1.1 Chronic medical condition 13

2.1.2 Complex care needs 13

2.2 SERVICES available under medicare 13

2.2.1 Number of services per year 13

2.2.2 Service length and type 14

2.3 ELIGIBLE ALLIED HEALTH PROFESSIONALS 14

2.3.1 Registering with Medicare Australia 16

2.3.2 Changes to provider details 16

2.3.3 Allied health membership of a multidisciplinary care team 16

2.4 REFERRAL REQUIREMENTS 16

2.4.1 Referral form 16

2.4.2 Referral validity 17

2.5 Reporting requirements 17

2.6 FURTHER INFORMATION 17

ITEM DESCRIPTORS 18

PART 3
GROUP ALLIED HEALTH SERVICES FOR PATIENTS WITH TYPE 2 DIABETES
(MBS ITEMS 81100 TO 81125) 25

3.1 ELIGIBLE PATIENTS 25

3.2 SERVICES AVAILABLE UNDER MEDICARE 25

3.2.1 Assessment for group services (MBS items 81100, 81110 and 81120) 25

3.2.2 Group services (MBS items 81105, 81115 and 81125) 25

3.2.4 Multiple services on the same day 26

3.3 ELIGIBLE ALLIED HEALTH PROVIDERS 26

3.4 REFERRAL REQUIREMENTS 27

3.5 REPORTING REQUIREMENTS 27

3.6 FURTHER INFORMATION 27

ITEM DESCRIPTORS 28

PART 4
FOLLOW-UP ALLIED HEALTH SERVICES FOR aboriginal AND torres strait islander PEOPLES WHO HAVE HAD A HEALTH ASSESSMENT
(MBS ITEMS 81300 TO 81360) 31

4.1 ELIGIBLE PATIENTS 31

4.2 SERVICES AVAILABLE UNDER MEDICARE 31

4.3 ELIGIBLE ALLIED HEALTH PROFESSIONALS 31

4.4 REFERRAL REQUIREMENTS 33

4.5 REPORTING REQUIREMENTS 34

ITEM DESCRIPTORS 35

PART 5
PSYCHOLOGICAL THERAPY SERVICES
(MBS items 80000 to 80020) 42

5.1 ELIGIBLE PATIENTS 42

5.2 SERVICES AVAILABLE UNDER MEDICARE 42

5.2.1. Eligible psychological therapy services 42

5.2.2 Number of services per year 43

5.2.3 Service length and type 44

5.3 Eligible allied health professionals 44

5.3.1 Eligible clinical psychologists 44

5.3.2 Registering with Medicare Australia 44

5.4 REFERRAL REQUIREMENTS 44

5.4.1 Referrals 44

5.4.2 Referral validity 45

5.5 REPORTING REQUIREMENTS 45

5.6 FURTHER INFORMATION 46

ITEM DESCRIPTORS 47

PART 6
FOCUSSED PSYCHOLOGICAL STRATEGIES
(MBS ITEMS 80100 to 80170) 49

6.1 Eligible patients 49

6.2 SERVICES AVAILABLE UNDER MEDICARE 49

6.2.1 Eligible FPS services 49

6.2.2 Number of services per year 50

6.2.3 Service length and type 51

6.3 ELIGIBLE ALLIED HEALTH PROfessionals 51

6.3.1 Continuing professional development (CPD) for allied mental health professionals providing focussed psychological strategies (FPS) services 52

6.4 REFERRAL REQUIREMENTS (GPs, PSYCHIATRISTS OR PAEDIATRICIANS TO ALLIED MENTAL HEALTH PROFESSIONALS) 52

6.4.1 Referrals 52

6.4.2 Referral validity 53

6.5 REPORTING REQUIREMENTS 53

6.6 FURTHER INFORMATION 54

ITEM DESCRIPTORS 55

PART 7
PREGNANCY SUPPORT COUNSELLING
(MBS ITEMS 81000 TO 81010) 59

7.1 ELIGIBLE PATIENTS 59

7.2 SERVICES AVAILABLE UNDER MEDICARE 59

7.2.1 Number of services per year 59

7.2.2 Service length and type 59

7.3 ELIGIBLE ALLIED HEALTH PROFESSIONALS 59

7.3.1 Registering with Medicare Australia 60

7.4 REFERRAL REQUIREMENTS 60

7.4.2 Referral validity 61

7.4.3 Subsequent referrals 61

7.5 FURTHER INFORMATION 61

ITEM DESCRIPTORS 62

PART 8
children with autism, pervasive developmental disorder or AN ELIGIBLE DISABILITY
(MBS ITEMS 82000 TO 82035) 63

8.1 ELIGIBLE PATIENTS 63

8.2 ALLIED HEALTH SERVICES AVAILABLE UNDER MEDICARE 64

8.2.1 Number of assessment services 64

8.2.2 Number of treatment services 64

8.2.3 Service length and type 65

8.3 ELIGIBLE ALLIED HEALTH PROFESSIONALS 65

8.4 REFERRAL REQUIREMENTS 66

8.4.1 Referrals 66

8.4.2 Referral validity 67

8.5 REPORTING REQUIREMENTS 67

ITEM DESCRIPTORS 68

PART 9
DIAGNOSTIC AUDIOLOGY SERVICES
(MBS ITEMS 82300 TO 82332) 72

9.1 OVERVIEW 72

9.2 Requesting arrangements 72

9.3 Eligibility requirements for audiologists 73

9.4 Reporting requirements 73

9.5 NOTES ON DIAGNOSTIC AUDIOLOgy SERVICES 73

9.5.1 Brain Stem Evoked Response Audiometry - (Item 82300) 73

9.5.2 Non-determinate Audiometry - (Item 82306) 73

9.5.3 Conditions for Audiology Services - (Items 82309 to 82318) 73

9.5.4 Oto-Acoustic Emission Audiometry - (Item 82332) 73

ITEM DESCRIPTORS 74



PART 1
INFORMATION FOR ALLIED HEALTH PROVIDERS

1.1 ELIGIBLE ALLIED HEALTH PROVIDERS

To be eligible to provide services under Medicare, allied health professionals must meet specific eligibility requirements, be in private practice and be registered with Medicare Australia. The specific requirements for each Medicare item are detailed in the relevant Part of this document.

Provider registration forms can be obtained from Medicare Australia on 132 150 or at http://www.humanservices.gov.au.

Chiropractors, osteopaths, physiotherapists and podiatrists who are already registered with Medicare Australia to order diagnostic imaging under Medicare, do not need to re-register to provide services under these initiatives.

1.2 ELIGIBILITY OF PATIENTS

Eligibility requirements for each of the allied health items available under Medicare are outlined below. The requirements for each item are also detailed in the relevant Part of this document. If there is any doubt about a patient’s eligibility, Medicare Australia will be able to assist. Allied health professionals or GPs can call Medicare Australia on 132 150 to check. Patients can call Medicare Australia on 132 011.

Eligible patients

Number of allied health services per patient

Allied health professional eligible to provide the service

Patients who have a chronic (or terminal) medical condition and complex care needs requiring a multidisciplinary approach (refer Part 2)

Up to five individual services (in total) per calendar year (no exceptions)

Aboriginal and Torres Strait Islander health practitioner

Aboriginal health worker

Audiologist

Chiropractor

Diabetes educator

Dietitian

Exercise physiologist

Mental health worker

Occupational therapist

Osteopath

Physiotherapist

Podiatrist

Psychologist

Speech pathologist

Aboriginal and Torres Strait Islander peoples who have had a health check (refer Part 3)

Up to five individual services (in total) per calendar year

(Note: these services are in addition to the five individual services for patients with a chronic or terminal medical condition and complex care needs)

Aboriginal and Torres Strait Islander health practitioner

Aboriginal health worker

Audiologist

Chiropractor

Diabetes educator

Dietitian

Exercise physiologist

Mental health worker

Occupational therapist

Osteopath

Physiotherapist

Podiatrist

Psychologist

Speech pathologist

Patients who have type 2 diabetes (refer Part 4)

One individual assessment and up to eight group sessions per calendar year

(Note: these services are in addition to the five individual services for patients with a chronic or terminal medical condition and complex care needs)

Diabetes educator

Dietitian

Exercise physiologist

Patients with an assessed mental disorder (refer Parts 5 and 6)

Up to ten individual services and an additional six services in exceptional circumstances (to a maximum of 16 individual services per patient from 1 March 2012 to 31 December 2012) and up to ten group therapy services per calendar year.

Services provided under the Access to Allied Psychological Services (ATAPS) should not be used in addition to the ten (up to 16 services where exceptional circumstances apply) psychological therapy services (items 80000 to 80020), focussed psychological services-allied mental health services (items 80100 to 80170 and/or GP focussed psychological strategies services (items 2721 to 2727).

Clinical psychologist

Psychologist

Occupational therapist

Social worker

(Note: services can also be provided by a qualified medical practitioner)

Women who are concerned about either a current pregnancy, or one that occurred in the previous 12 months (refer Part 7)

Up to three services per pregnancy

Psychologist

Social worker

Mental health nurse

(Note: services can also be provided by a qualified medical practitioner)

Children with autism, pervasive developmental disorder (PDD) or an eligible disability – aged under 13 years for diagnosis services and under 15 years for treatment services (refer Part 8)

Up to four services for assessment (in total per child) and up to 20 early intervention treatment services (in total per child).

Audiologist

Occupational therapist

Optometrist

Orthoptist

Physiotherapist

Psychologist

Speech pathologist

Patients with potential medical conditions (ear disease or related disorders), including patients whose hearing loss may be able to be corrected by surgery or medical intervention (refer Part 9)

Diagnostic audiology services, as specified in the written request from the Ear, Nose and Throat specialist or neurologist.

A request may be for more than one service making up a single audiological assessment, but cannot be for more than one audiological assessment.

Audiologist

A calendar year is the one-year period of time that begins on 1 January and ends on 31 December.

1.3 GENERAL PRACTITIONER (GP)

In this document, a reference to a GP is a generic reference to a medical practitioner (including a general practitioner, but not including a specialist or consultant physician).



1.4 MULTIPLE CONSULTATIONS ON THE SAME DAY

Consultations that run longer than the minimum time specified in the item descriptor should be billed as a single consultation. For payment of a benefit/rebate for more than one consultation with a patient on the same day by the same allied health professional, the subsequent consultation must not be a continuation of the initial consultation (except in the case of items 81105, 81115, 81125 and the autism/PDD or disability items 82000 - 82035).



1.5 SERVICE REQUIREMENTS

The service requirements for each allied health item are contained in the item descriptors provided at the end of each Part of this document. These are legislative requirements contained in the Health Insurance (Allied Health Services) Determination 2011 (as amended) and therefore must be met before the item can be claimed.

For any service listed on the MBS to be eligible for a Medicare rebate, the service must be provided in accordance with the provisions of all relevant Commonwealth and State and Territory laws.



1.6 MEDICARE BENEFIT/REBATE

The amount of the Medicare benefit (rebate) for each item is provided in the item descriptor for that item. These amounts are generally indexed on 1 November of each year.



1.7 DIRECT (BULK) BILLING

The allied health provider may choose to accept the amount of the Medicare benefit/rebate that is payable to the patient as full payment for the service. In such cases, the patient assigns his/her Medicare benefit to the provider, and the provider is not legally able to charge the patient any amount in addition to the Medicare benefit.

Where the patient is bulk billed, he/she will have no out-of-pocket costs.



1.8 FEE SETTING AND OUT-OF-POCKET COSTS

With the exception of participating optometrists, allied health professionals are free to determine their own fees for the professional service. Charges in excess of the Medicare benefit are the responsibility of the patient. However, out-of-pocket costs will count toward the Medicare Safety Net for the patient. Allied health services in excess of the maximum number of Medicare rebateable services for each item (e.g. five individual allied health services per calendar year for patients with a chronic or terminal illness) will not attract a Medicare benefit, and the Safety Net Arrangements will not apply to costs incurred for such services.



1.9 MEDICARE SAFETY NET

For information about the original and the extended Medicare Safety Nets, refer to the Explanatory notes for the Medicare Benefits Schedule (MBS).



1.10 PUBLICLY FUNDED SERVICES AND 19(2) EXEMPTIONS

Medicare rebates for allied health items do not apply to services that are already funded by the Commonwealth or State or Territory governments or services provided to an admitted patient of a public hospital.

However, where an exemption under section 19(2) of the Health Insurance Act 1973 has been granted to an Aboriginal Community Controlled Health Service or State/Territory Government health clinic, the allied health items can be claimed for services provided by eligible allied health professionals salaried by, or contracted to, the service or clinic. All requirements of the items must be met, including registration of the allied health professional with Medicare Australia.



1.11 PRIVATE HEALTH INSURANCE

Patients with private health coverage need to decide if they will use Medicare or their private health ancillary cover to pay for these allied health services. They cannot use their private health ancillary cover to ‘top up’ the Medicare rebate paid for the service.



1.12 CLAIMING FROM MEDICARE

Information on the different Medicare claiming options available to providers is available at http://www.medicareaustralia.gov.au/provider/medicare/claiming/index.jsp

1.12.1 Billing practices contrary to the Act

Under the Health Insurance Act 1973 (as amended), it is not permissible to:

  1. Include the cost of a non-clinically relevant service in a consultation charge. Medicare benefits can only be paid for clinically relevant services. If an allied health professional chooses to use a procedure that is not generally accepted in their profession as necessary for the treatment of the patient, the cost of this procedure cannot be included in the fee for a Medicare item. Any charge for non-clinically relevant services must be separately listed on the account and not included in the fee billed to Medicare.

  2. Include an amount for goods supplied for the patient to use at home in the consultation charge (e.g. wheelchairs, oxygen tanks, continence pads). Charges can be levied for these items, but they must be listed separately on the account and not billed to Medicare.

  3. Charge part or all of an in-patient procedure to an out-patient consultation. If an allied health professional charges part or all of an in-patient procedure to an out-patient consultation, the account issued by the practitioner is not an accurate statement of the services provided and would constitute a false or misleading statement.

  4. Re-issue modified accounts to include other charges and out-of-pocket expenses not previously included in the account. The account issued to a patient by an allied health professional must state the amount charged for the service provided and truly reflect what occurred between the patient and practitioner. While re-issuing an account to correct a genuine error is legitimate, if an account is re-issued to increase the fee or load additional components to the fee, the account is not a true statement of the fee charged for the service and would constitute a false or misleading statement.

Where a Medicare benefit has been inappropriately paid, Medicare Australia may request recovery of that benefit from the practitioner concerned.

1.13 CHANGES TO PROVIDER DETAILS

Allied health providers must notify Medicare Australia in writing of all changes to mailing details to ensure that they continue to receive any updates about Medicare rebateable allied health services.

1.14 MEDICARE AUSTRALIA CONTACT DETAILS

The Department of Human Services (Medicare Australia) is responsible for the operation of Medicare and the payment of Medicare benefits.

Medicare Australia contact details

Postal: Medicare, GPO Box 9822, in the Capital City in each State

Telephone: Australia wide at the cost of a local call.

Provider enquiries: 132 150

Public enquiries: 132 011

1.15 DEPARTMENT OF HEALTH AND AGEING CONTACT DETAILS FOR ITEMS IN THIS SCHEDULE

Telephone: 02 6289 1555

Email: mbsonline@health.gov.au

Internet: www.health.gov.au/mbsprimarycareitems or http://www.mbsonline.gov.au/

This publication, Medicare Benefits Schedule - Allied Health Services, is also available on the Department of Health and Ageing Internet site at www.health.gov.au/mbsonline.

PART 2
INDIVIDUAL ALLIED HEALTH SERVICES FOR PATIENTS WHO HAVE A CHRONIC (OR TERMINAL) CONDITION AND COMPLEX CARE NEEDS
(MBS ITEMS 10950 TO 10970)

2.1 ELIGIBLE PATIENTS

Patients in the community or private in-patients of a hospital may be eligible for individual allied health services (items 10950-10970) if they have a chronic or terminal medical condition and complex care needs that are being managed by their GP through the following Chronic Disease Management (CDM) services:

  • A GP Management Plan – MBS item 721 (or review item 732); and

  • Team Care Arrangements – MBS item 723 (or review item 732).

Patients who are permanent residents of an aged care facility may be eligible for individual allied health services (items 10950-10970) if they have a chronic or terminal medical condition and complex care needs and their GP has contributed to a multidisciplinary care plan prepared for them by the aged care facility or to a review of such a plan (item 731).

The allied health services must be directly related to management of the patient’s chronic condition/s.

Only the GP can determine whether the patient’s chronic condition would benefit from allied health services and the need for such services must be identified in the patient’s care plan.

2.1.1 Chronic medical condition

A chronic medical condition is one that has been or is likely to be present for at least six months (e.g., asthma, cancer, cardiovascular illness, diabetes mellitus, musculoskeletal conditions and stroke). There is not a comprehensive list all the possible medical conditions that either are/are not regarded as a chronic medical condition for the purposes of the CDM items. Whether a patient is eligible for CDM items and associated allied health items is essentially a matter for the GP to determine, using their clinical judgement and taking into account both the eligibility criteria and the general guidance material.

2.1.2 Complex care needs

A patient is considered to have complex care needs if they require care from a multidisciplinary team consisting of their GP and at least two other health or care providers, each of whom provides a different kind of treatment or service to the patient.



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