NR 2020/0610
Answer
In our opinion, yes.
Context
I am a nephrologist working in both public and private hospitals, including a private dialysis facility. I have private patients on dialysis whom I am responsible for and I supervise their treatment. Dialysis patients are admitted for each treatment. I am frequently contacted by staff for ongoing issues, but I only get to physically see the patients about once in a month or so due to timing issues. Currently, I bulk bill private patients item number 116, but only when I see them face to face (F2F). I have recently learned about item 13103, which someone said I could bill even when I am not present. Can I legally claim item 13103 when these patients are having their dialysis treatment and I am not seeing them F2F, but am working in the background? I am in Australia.
Relevant Legislative Provisions
Health Insurance Regulations 2018
Health Insurance (General Medical Services Table) Regulations (No.1) 2020
Other Relevant Materials
N/A
Case law
N/A
Departmental Interpretation
mbsonline (accessed 29 June 2020)
“TN.1.2 – Haemodialysis – (Items 13100 and 13103)
Item 13100 covers the supervision in hospital by a medical specialist for the management of dialysis, haemofiltration, haemoperfusion or peritoneal dialysis in the patient who is not stabilised where the total attendance time by the supervising medical specialist exceeds 45 minutes.
Item 13103 covers the supervision in hospital by a medical specialist for the management of dialysis, haemofiltration, haemoperfusion or peritoneal dialysis in a stabilised patient, or in the case of an unstabilised patient, where the total attendance time by the supervising medical specialist does not exceed 45 minutes.
AN.0.6 Patient Eligibility
Medicare covers services provided only in Australia.
GN.12.31 Services rendered on behalf of medical practitioners
Supervision from outside of Australia is not acceptable.“
Detailed Reasoning
Services in the Medicare scheme use specific words and phrases that are intended to convey consistent meaning. Of course, this does not always work in practice, but there are two words found in many item descriptions that tend to be less controversial than others. They are: ‘attendance’ and ‘supervision.’
Whilst ‘attendance’ usually means physical, personal attendance (ie: you and the patient in the same room at the same time face to face), Regulation 1.2.6 of the General Medical Services Table has, for some time, been crafted to provide that telepsychiatry, home dialysis item 13104, and pre-Covid telehealth services, all meet the requirements of ‘personal attendance.’ So, you can also bill for the supervision of your patients on days when they are at home on dialysis using item 13104, and you do not have to personally attend their homes.
A provision in the Covid telehealth Determinations has also ensured that billing Covid telehealth services meets the requirements for ‘personal attendance.’ For more about the Covid telehealth services please read the bulletins at this link.
Item 13103 is positioned in a group of items specifically for the supervision of dialysis for inpatients and patients at home. See below table.
Subgroup 2 – Dialysis
| 13100 | Supervision in hospital by a medical specialist of—haemodialysis, haemofiltration, haemoperfusion or peritoneal dialysis, including all professional attendances, if the total attendance time on the patient by the supervising medical specialist exceeds 45 minutes in one day | 138.85 | ||
| 13103 | Supervision in hospital by a medical specialist of—haemodialysis, haemofiltration, haemoperfusion or peritoneal dialysis, including all professional attendances, if the total attendance time on the patient by the supervising medical specialist does not exceed 45 minutes in one day | 72.35 | ||
| 13104 | Planning and management of home dialysis (haemodialysis or peritoneal dialysis) for a patient with end‑stage renal disease and supervision of the patient on self‑administered dialysis, if the attendance is by a consultant physician in the practice of the consultant physician’s specialty of renal medicine | 150.30 |
Item 13103 is not an attendance item, it is a supervision item.
The item specifically commences with the word ‘supervision’ as opposed to ‘attendance’ and while it states, ‘supervision in hospital’ it is unclear whether it is the patient or the doctor that has to be ‘in hospital’. However, further clues are revealed when it is noted that the item attracts both an inpatient and an outpatient rebate.
This is difficult to reconcile, because it means that a Medicare rebate is payable for this service if provided to an outpatient. So the question begs – how can you supervise ‘in hospital’ a patient who isn’t in hospital? And if the patient isn’t in hospital then presumably you (the doctor) wouldn’t need to be either.
Further, if you were onsite at a hospital and were able to drop down to the dialysis unit to see the patient face to face, you would claim either item 119 or 116 depending on other factors.
Whilst this item does refer to attendances as being included, there is no specific requirement to attend. Put another way, the item is designed to acknowledge you would be working in the background as you have said and may or may not have time to see the patient face to face (F2F). If you do see the patient F2F you would claim the relevant attendance item, if you don’t, but are actively monitoring and responding to queries throughout the dialysis, item 13103 can be claimed. You cannot claim both this item and an attendance though – it includes all attendances if you make any.
On balance, our view is that you can claim this item in the circumstances you have described for your private admitted patients having dialysis, because the item is a supervision item and you have described your supervision of the patient’s dialysis by ‘working in the background’. Being onsite at the clinic and dropping by to see them would of course be optimal, but there is no clear requirement for this to occur. Keep meticulous records of every touch point you have with the patient for each treatment to support the claiming of this item, and do not claim it if you do not provide a service, meaning, you must actively take responsibility for the service and be involved, evidenced by your entries (not someone else’s such as nurse) in the clinical records.
Please also note the time requirements of these items – you need to add up the total time you spend responding to queries and calls and attending (if you do attend) – if less than 45 minutes, use item 13103, if more, use item 13100 and again, always keep adequate and contemporaneous records to support your claims.
Examples and other relevant information
Billing while you are outside of Australia, including supervising from outside of Australia, is illegal. Please see GA 2020/065
Who this applies to
All nephrologists / renal physicians.
When this applies
Since the item was introduced.