Medicare’s advisory service has responded at length to a GP’s question about a complex billing situation.
Last month TMR published a piece by Dr Louise Stone including her questions to the Medicare advice line AskMBS about how to bill correctly for seeing a patient with mental and physical health care needs.
Dr Stone wanted to know how she might bill for a consultation combining these elements without either running foul of the PSR or letting her patient be financially discriminated against because her presenting condition was a mental health one.
This was prompted in part by a recent advisory bulletin stipulating that if a mental health item is available, that is what should be billed, rather than a general attendance item, even though a patient may be worse off in rebate dollar terms.
This in turn followed a spray by Professor Ian Hickie in MJA Insight claiming that GPs don’t do enough mental health follow-up, judging from Medicare claims data – which, as Dr Stone et al. responded, fails to take into account the large amount of mental health care delivered by GPs who don’t necessarily bill explicitly mental health items.
The question also raises the problem of the criterion that a patient have a “mental disorder” to qualify for an item, even though aspects of mental health may not have a distinct disorder at their core – for example, trauma associated with domestic violence.
Below is the full response (complete with disclaimer) from the AskMBS service on how to bill the patient. How helpful is it? You may judge.
Re: FW: Mental and physical health GP item numbers [SEC=OFFICIAL]
Dear Dr Stone,
We are writing in response to your recent enquiry, submitted to the Department of Health and Aged Care’s AskMBS advice service on 17/08/2022.
This response responds directly to your enquiry of 17 August 2022 (Ticket 26955), but also addresses issues raised in your earlier enquiry of 11 August 2022 (Ticket 26844).
Firstly, please note that AskMBS has no involvement in the Department of Health and Aged Care’s direct Medicare compliance functions, and enquiries to AskMBS are treated in strictest confidence. AskMBS cannot comment on the implications of any issues raised in an enquiry for possible compliance action.
Note also that AskMBS cannot direct providers of MBS services as to which item to bill in a particular scenario, as this will involve clinical and other variables of which AskMBS cannot have full visibility. Under MBS arrangements, it is always the health professional’s responsibility to consider the clinical circumstances of any services they render and to determine the appropriate MBS item(s) to claim, if any. They should also exercise care to ensure that their conduct in relation to rendering the services cannot be characterised as inappropriate practice (i.e. practice that a practitioner’s peers could reasonably conclude was unacceptable to the general body of their profession).
However, AskMBS can provide advice on MBS principles and requirements to assist in your decision making. Importantly, Medicare benefits are only payable for clinically relevant services. A medical service is considered clinically relevant if it is generally accepted in the medical profession as necessary for the appropriate treatment of the patient.
It is a fundamental principle of Medicare that the item that best describes the service is the item that should be claimed for that service Additionally, an MBS item can only be claimed when all item requirements, as set out in the item descriptor and associated explanatory notes, have been met in full. Of particular relevance to your enquiry, Medicare benefits may be paid for more than one attendance for a patient on the same day, provided that the second (and any following) attendances are not a continuation of the initial or earlier attendances, each service is distinct and clinically relevant, the requirements of each item (including time requirements) are fully independently met, and there is no duplication of services.
With regard to the scenario described in your enquiry, you do not specify the total duration of the attendance concerned. However, AskMBS can provide the following comments on the options you present.
1. If the consultation was only about her mental health, she is eligible to claim a mental health item number (2713) which attracts a rebate of $75.80.
This would be appropriate if the attendance was of at least 20 minutes’ duration and all item requirements were met.
2. If I restrict the mental health component of the consultation to less than 20 minutes, she is eligible to claim a normal consultation item number (44) which attracts a rebate of $113.30.
No dedicated mental health treatment item is available for an attendance of less than 20 minutes’ duration. If a mental health related consultation does take less than 20 minutes, the appropriate time-tiered general attendance item may be billed. However, the duration of the treatment of a particular issue should not be manipulated simply to claim an MBS item with a higher benefit. The time spent addressing a particular issue should be determined by clinical need and optimal outcomes.
3. If I do more than 20 minutes on her mental health and less than 20 minutes on her physical health, you state it “would be theoretically possible” to claim a mental health item number (2713) and a normal consultation item number (23) giving Melissa a rebate of $115.55.
On the face of it, it would be appropriate to bill items 2713 and 23 for the service described. The caveat “theoretically possible” is included only to acknowledge that the requirements of both items must be fully and independently met, and that this is a matter for the professional judgement of the GP in each real-world case.
With regard to the “unallocated” minutes you refer to in your enquiry, this is a matter for your professional judgement, taking into account the particulars of the consultation. However, AskMBS can advise that a ‘template’ of the type described is not a requirement under MBS billing arrangements, but it may assist with record keeping.
The Health Insurance (Professional Services Review Scheme) Regulations 2019 (the PSR regulations) specify that a Medicare provider keep adequate and contemporaneous patient records. Under the PSR Regulations, the minimum standards for an adequate patient or clinical record are that it must:
•clearly identify the name of the patient;
•contain a separate entry for each attendance by the patient for a service and the date on which the service was rendered or initiated;
•for each entry, contain clinical information adequate to explain the type of service rendered or initiated; and
•for each entry, be sufficiently comprehensible that another practitioner, relying on the record, can effectively undertake the patient’s ongoing care.
To be contemporaneous, the PSR Regulations require the patient or clinical record to be completed at the time that the service was rendered or initiated or as soon as practicable afterwards. Further information is available at explanatory note AN.0.18 to the MBS available at the following link:
http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=AN.0.18&qt=noteID&criteria=adequate%20an
Medical records can be kept as physical files or electronically. Electronic files must be capable of being printed. All medical records, regardless of how they are kept, must be stored in a manner that:
•preserves the confidentiality of the patient;
•protects against misuse or unauthorised access, disclosure or modification;
•prevents damage, loss or theft; and
•allows reasonable access to ensure continuity of treatment.
Your enquiry raises a number of additional issues which are addressed below.
1. Patient eligibility for MBS mental health services. AskMBS confirms that it would not be appropriate to bill a mental health item for a patient who does not have a mental health disorder. As explanatory note AN.0.56 stipulates, these items are for patients with a mental disorder who would benefit from a structured approach to the management of their treatment needs.
2. The interaction of MBS billing and ethical care. AskMBS provides advice on the interpretation and application of MBS items, explanatory notes and associated legislation. AskMBS cannot comment on matters of professional conduct and suggests that you discuss such matters with your professional body.
3. ‘Order of service’ requirements. The purpose of the explanatory notes you cite is not to provide prescriptive guidance on the billing of services addressing more than one clinical issue, but to highlight the general co-claiming principles outlined above. In order for more than one attendance to be billed for the same patient on the same day:
•the second (and any following) attendances cannot be a continuation of the initial or earlier attendances;
•each service must be distinct and clinically relevant;
•the requirements of each item (including time requirements) must be fully independently met; and
•there can be no duplication of services.
Should you require further clarification please contact askmbs@health.gov.au, quoting reference [_____].
AskMBS publishes advisories which summarise frequently asked questions and answers on related topics about the correct billing of MBS items. Please see these at the following link: https://www1.health.gov.au/internet/main/publishing.nsf/Content/AskMBS-Email-Advice-Service.
Thank you for contacting AskMBS.
We invite you to provide feedback at the link below about this AskMBS response and any other recent interactions with the AskMBS advice service. You will not be required to provide any personal or identifying information and your response will be treated in confidence.
Yours sincerely
AskMBS
Department of Health and Aged Care
E: askmbs@health.gov.au
IMPORTANT: ADVICE DISCLAIMERS
AskMBS provides Medicare claiming information specific to the circumstances of each enquiry. This response has been prepared specifically for the circumstances given in your enquiry to help you make an informed decision. This response is not general guidance and therefore may not be suitable for application to other claiming situations, including variations of this enquiry, without further consultation with the Department of Health and Aged Care. Similarly, responses previously provided by AskMBS may be unsuitable or inappropriate for application to this enquiry. This response is not legal advice and providers may wish to obtain their own independent legal advice to ensure they comply with their obligations.
