GA 2020/0823
Answer
No.
Context
Question: If the same treating rehab physician sees a patient following discharge in their outpatient rooms, can this be billed as a 132 (obviously with a relevant referral)? I am assuming not as the physician has seen this person during their inpatient stay, and therefore I am assuming that a 116 is how this would be billed but wanted to clarify if the inpatient and outpatient episodes are to be considered in isolation of each other?
Relevant considerations here are the ‘clinical relevance principle’, and the ‘single course of treatment principle’.
Relevant Legislative Provisions
Health Insurance Regulations 2018
Health Insurance (General Medical Services Table) Regulations (No. 2) 2020
Other Relevant Materials
Please read this answer in conjunction with GA 2020/0820, GA 2020/0821, GA 2020/0822 and OH 2020/0713
Case law
N/A
Departmental Interpretation
mbsonline.gov.au (accessed 27 July 2020)
Definition of a Single Course of Treatment
“A single course of treatment involves an initial attendance by a specialist or consultant physician and the continuing management/treatment up to the stage where the patient is referred back to the care of the referring practitioner. It also includes any subsequent review of the patient’s condition by the specialist or the consultant physician that may be necessary… The receipt by a specialist or consultant physician of a new referral following the expiration of a previous referral for the same condition(s) does not necessarily indicate the commencement of a new course of treatment involving the itemisation of an initial consultation.…“
servicesaustralia.gov.au (accessed 31 July 2020)
“Single course of treatment
A referral will cover a single course of treatment for the referred condition. A single course of treatment is an initial attendance by the specialist or consultant physician. The single course of treatment includes subsequent attendances for the continuing management of the condition until the patient is referred back to the referring practitioner.
A new referral doesn’t always mean a new course of treatment...”
Detailed Reasoning
The below content is an edited version of information provided in answer GA 2020/0821.
The starting point here is to return to Medicare billing basics and the legal requirement that clinical relevance underpins every decision to allocate an MBS item number to a service delivered.
Medicare benefits are payable to reimburse clinically relevant services only. If the service is not clinically relevant it should not be claimed through Medicare. A clinically relevant services is defined in the Health Insurance Act as follows:
“clinically relevant service means a service rendered by a medical or dental practitioner or an optometrist that is generally accepted in the medical, dental or optometrical profession (as the case may be) as being necessary for the appropriate treatment of the patient to whom it is rendered.”
The inclusion of the word ‘necessary’ in the definition imposes a high threshold requirement when selecting Medicare item numbers.
If you always base billing decisions on the clinically relevant services provided, rather than on financial objectives, you will be off to a good start.
The Single Course of Treatment Principle is described in the regulations as follows:
“(2) A single course of treatment for a patient:
(a) includes:
(i) the initial attendance on the patient by a specialist or consultant physician; and
(ii) the continuing management or treatment up to and including the stage when the patient is referred back to the care of the referring practitioner; and
(iii) any subsequent review of the patient’s condition by the specialist or consultant physician that may be necessary, whether the review is initiated by the referring practitioner or by the specialist or consultant physician; but
(b) does not include:
(i) referral of the patient to the specialist or consultant physician; or
(ii) an attendance (the later attendance) on the patient by the specialist or consultant physician, after the end of the period of validity of the last referral to have application under regulation 31 of the Health Insurance Regulations 1975 if:
(A) the referring practitioner considers the later attendance necessary for the patient’s condition to be reviewed; and
(B) the patient was most recently attended by the specialist or consultant physician more than 9 months before the later attendance.“
For the purposes of this question, the key point to understand is that a new referral and the patient moving from an inpatient setting to being reviewed in outpatient rooms does not trigger a new initial consultation as a matter of course. If you are treating the patient for the same condition it would usually not be clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132. The only time this would be appropriate is if you have a new referral AND the patient has developed a new condition requiring a new work up and treatment plan.
Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.
Examples and other relevant information
N/A
Who this applies to
All specialists eligible to claim items 132 and 133.
When this applies
Always