Do you get one item 132 and two item 133’s every 12 months?

Date of Answer: 2:53 pm  I  August 13, 2020

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Peer reviewed academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Academic article currently in peer review that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed item 132, then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading, as is our AIMAC course on Ethical Medical Billing.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always

Relevant AIMAC courses

Medicare Compliance Pack

Ethical Medical Billing and the Medicare Benefits Schedule

Record Keeping Requirements for Doctors and Anyone Claiming Medicare Benefits

The Rules of Referrals – includes locum billing rules

Date of Answer: 2:37 pm  I  August 31, 2020

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Peer reviewed academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Academic article currently in peer review that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

PSR Director’s Update June 2019

“An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.“

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed item 132, then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading, as is our AIMAC course on Ethical Medical Billing.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always

Relevant AIMAC courses

Medicare Compliance Pack

Ethical Medical Billing and the Medicare Benefits Schedule

Record Keeping Requirements for Doctors and Anyone Claiming Medicare Benefits

The Rules of Referrals – includes locum billing rules

Date of Answer: 2:44 pm  I  August 31, 2020

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Peer reviewed academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Academic article currently in peer review that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

PSR Director’s Update June 2019

“An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.“

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist and a rehabilitation physician (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed an initial consultation (for item 132 this will need to be 12 months), then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading, as is our AIMAC course on Ethical Medical Billing.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always

Relevant AIMAC courses

Medicare Compliance Pack

Ethical Medical Billing and the Medicare Benefits Schedule

Record Keeping Requirements for Doctors and Anyone Claiming Medicare Benefits

The Rules of Referrals – includes locum billing rules

Date of Answer: 5:56 pm  I  January 16, 2023

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Peer reviewed academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Academic article currently in peer review that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

PSR Director’s Update June 2019

“An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.“

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist and a rehabilitation physician (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed an initial consultation (for item 132 this will need to be 12 months), then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading, as is our AIMAC course on Ethical Medical Billing.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 2:49 pm  I  February 23, 2023

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Published academic journal article that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

PSR Director’s Update June 2019

“An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.“

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist and a rehabilitation physician (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed an initial consultation (for item 132 this will need to be 12 months), then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading, as is our AIMAC course on Ethical Medical Billing.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always

 

Date of Answer: 5:23 pm  I  March 1, 2023

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Published academic journal article that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

PSR Director’s Update June 2019

“An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.“

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist and a rehabilitation physician (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed an initial consultation (for item 132 this will need to be 12 months), then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 2:33 pm  I  May 15, 2023

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Published academic journal article that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

PSR Director’s Update June 2019

“An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.“

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist and a rehabilitation physician (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed an initial consultation (for item 132 this will need to be 12 months), then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 2:34 pm  I  May 15, 2023

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Published academic journal article that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

PSR Director’s Update June 2019

“An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.“

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist and a rehabilitation physician (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed an initial consultation (for item 132 this will need to be 12 months), then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 5:52 pm  I  May 16, 2023

GA 2020/0822

Answer

No.

Context

Doctor A worked in a public hospital outpatient department where she exercised a right of private practice. She thought that she was not automatically permitted to bill item 132 every 12 months, but had received contrary advice. Further, she was unclear about whether item 133 applies twice in the first year only or twice every year. She had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean she could bill item 133 40 times. This advice was incorrect.

Relevant considerations here are the ‘clinical relevance principle’, the ‘single course of treatment principle’, and the ‘locum tenens’ arrangements are also worth noting.

This answer should be read in conjunction with GA 2020/0820 and GA 2020/0821 and OH 2020/0713

Relevant Legislative Provisions

Health Insurance Act 1973

Health Insurance Regulations 2018

Health Insurance (General Medical Services Table) Regulations (No. 2) 2020

Other Relevant Materials

1. Academic journal article published in the Journal of Law and Medicine, with discussion around third party involvement in medical billing:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

2. Published academic journal article that includes direct quotes from interviewed doctors employed by public hospitals regarding third party involvement in their billing.

Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.

3. Academic journal article published in the Journal of Medicine and Philosophy.

Ethical Issues in Physician Billing Under Fee-For-Service Plans https://academic.oup.com/jmp/article-abstract/45/1/86/5700357?redirectedFrom=fulltext

Case law

PSR Director’s Update January 2020

“An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

• the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
• the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
• the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
• not all services were clinically indicated; and
• the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.”

PSR Director’s Update June 2019

“An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.“

Departmental Interpretation

mbsonline.gov.au (accessed 13 August 2020)

“Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

AN.0.23

Patients with at least two morbidities which can include complex congenital, development and behavioural disorders are eligible for these services when referred by their referring practitioner. 

Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate. 

Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12 month period. Should further reviews of the consultant physician treatment and management plan be required, the appropriate item for such service/s is 116. 

Preparation of the consultant physician treatment and management plan should be in consultation with the patient. If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient. A written copy of the consultant physician treatment and management plan should be provided to the referring medical practitioner, usually within two weeks of the consultant physician consultation.”

The department goes on to provide a guide to the content of the treatment and management plan including, examination, diagnosis, treatment plan and options, medication recommendations, social measures, other non-medication measures, indications for review, longer term management and any specific questions raised by the referring doctor.

Detailed Reasoning

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.

As the medical practitioner, you are primarily responsible for the item numbers billed under your name and provider number, irrespective of who processes the bills on your behalf. It is therefore worth keeping in mind the motivations of various third parties, illuminated by the following quote copied from the above academic article (Medicare Billing Law and Practice):

“…increasing corporatisation of medical practice could potentially be playing a role in the rising incidence of incorrect MBS billing, particularly in circumstances where employed or contracted medical practitioners are contractually bound or incentivised to meet targets or provide certain services to support the financial objectives of the corporate owner. Corporate owners and the Practice Managers they employ, may not necessarily be medically qualified and may have little understanding of Medicare billing requirements, focusing only on the value of each item in the schedule, rather than the important compliance provisions contained in the broader regulatory scheme.”

Third party involvement is now a known contributor to non-compliant medical billing both in the private and public sector – including in public hospital settings. The above academic article (Wading through Molasses) sheds light on this issue.

Returning to the question and the incorrect advice afforded Doctor A, your billing decisions should always be based on the clinically relevant services you have provided, evidenced in your adequate and contemporaneous records, NOT what item numbers could be claimed NOR what item numbers your employer would prefer you claim to meet their financial objectives.

Further, as is evident from the recent adverse findings of the Professional Services Review in relation to an endocrinologist and a rehabilitation physician (quoted above), items 132 and 133 include onerous time and reporting requirements. You must ensure you meet all of the item requirements not just some. So if your appointment schedule (which will be the first thing Medicare reviews in an audit) does not support a 45 minute (item 132) or 20 minute (item 133), appointment length, you are already non-compliant. Noting this is 45 or 20 minutes with the patient, not 15 minutes with the patient and then 30 minutes making phone calls and writing up notes after the patient has left.

In addition, you must provide or review a detailed management plan, you must personally attend the patient, and all of this should be evidenced in your adequate and contemporaneous records, signed by you.

Moving now to the next principle for consideration, the fact that 365 days have passed and a new 12 month period has begun, does not automatically mean another 132 can be claimed. In addition to the ‘clinical relevance principle’, the ‘single course of treatment principle’ must be taken into account.

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 here is that a new referral and even a new hospital admission does not necessarily mean you can claim a new initial attendance item. If you are treating the patient for the same condition in year two, and it is neither clinically relevant nor necessary to spend 45 minutes with the patient to manufacture the claiming of another item 132, do not claim it.

If on the other hand the patient does require a new work up and management plan because it is clinically relevant and necessary, and more than 9 months have passed since you last claimed an initial consultation (for item 132 this will need to be 12 months), then there is no legal barrier to you claiming it again. Be sure to keep adequate and contemporaneous notes (which is a legal requirement) to support your billing decisions.

Finally, the Locum Tenens Arrangements come into play.

There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.

Medicare’s interpretation of the locum arrangements has always been the same which is that if an initial consultation has already taken place under a referral, a locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.

In practice how this works is, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation such as item 132 if appropriate, even if it means the doctor to whom the referral is named becomes blocked from claiming item 132 when she sees the patient. It’s basically a first in first served system.

It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations. You can learn more about this, including how to deal with the situation when the locum claims a 133 but did not claim the 132, by clicking on the links to the associated answers above.

Examples and other relevant information

If you ever hear a phrase like this:

‘You get one 132 then two 133’s then after that it’s all 116’s until year end when you start again with another 132.’

Ignore it. It is wrong in every sense – legal and ethical.

You do not ‘get’ anything when billing to Medicare. Adopting a practice of billing for what you do (which should be clinically relevant and necessary to treat the patient), not for what is able to be billed (based on financial objectives), is the correct approach.

Sometimes, these types of decisions are not so much legal as ethical, so it is always worth remembering that the sustainability of Medicare depends heavily on each individual doctor’s integrity.

The above cited article, by a Canadian academic, on the ethics of medical billing in fee-for-service schemes such as Medicare, is highly recommended reading.

Who this applies to

All specialists eligible to claim items 132 and 133.

When this applies

Always