GP 2024 / 0368
Answer
In our opinion, no.
Context
At our practice we do not hold the billing, and we charge item 723 on the same day as the GPMP (721). I have heard of other practices who withhold the 723 billing until signed faxes are exchanged with team care members so that it is all documented before charging.
Relevant legislative provisions
Health Insurance Act 1973, section 81(1)
Health Insurance (General Medical Services Table) Regulations 2021, Clause 2.16.4 and 2.16.13
Health Insurance Regulations 2018, Clause 49
Health Insurance (Professional Services Review Scheme) Regulations 2019, Clause 6
Case law
N/A
Departmental interpretation
See Medicare Benefits Schedule – Note AN.0.47 at mbsonline.gov.au
Detailed reasoning
First a few overarching principles.
- Medicare is a patient insurance scheme not a provider payment scheme.
- GPs refer to various other health practitioners all the time but ultimately it is the patient who decides whether they action your referrals.
- The MBS is not an instrument of parliament and therefore has no legal force or effect. The MBS book itself states:
“This book is not a legal document, and, in cases of discrepancy, the legislation will be the source document for payment of Medicare benefits.”
The best way to describe the MBS is that it is a departmental user guide, so it is always necessary to examine the relevant law that underpins the contents of the guide. There are often subtle differences between the language of the law and the paraphrasing in the guide which are important.
- The threshold legal requirement before any Medicare service can be claimed is that it must be clinically necessary. So always ask yourself – What does this patient need? As opposed to How much can I get?
There are several legal provisions that need to be read together to answer this question. The first two relate to service provision and then we need to look at record keeping.
First – the service
Here is the legal description of item 723 in the regulations (not the MBS) with emphasis added to the word “coordinate”.
2.16.13 Items in Subgroup 1 of Group A15
“723
Attendance by a general practitioner (not including a specialist or consultant physician), to coordinate the development of team care arrangements for a patient (other than a service associated with a service to which any of items 735 to 758 apply)”
And below is the statutory meaning of “coordinate” a TCA with key terms underlined.
2.16.4 Meaning of coordinating the development of team care arrangements
(1) In items 723 and 230:
coordinating the development of team care arrangements means a process by which a general practitioner (for item 723) or a prescribed medical practitioner (for item 230):
(a) in consultation with at least 2 collaborating providers, each of whom provides a different kind of treatment or service, and one of whom may be another medical practitioner, makes arrangements for the multidisciplinary care of the patient; and
(b) prepares a document that describes the following:
(i) treatment and service goals for the patient;
(ii) treatment and services that collaborating providers will provide to the patient;
(iii) actions to be taken by the patient;
(iv) arrangements to review the matters mentioned in subparagraphs (i), (ii) and (iii) by a day mentioned in the document; and
(c) undertakes all of the following activities:
(i) explains the steps involved in the development of the arrangements to the patient and the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees);
(ii) discusses with the patient the collaborating providers who will contribute to the development of team care arrangements, and provide treatment and services to the patient under those arrangements;
(iii) records the patient’s agreement to the development of team care arrangements;
(iv) gives the collaborating provider a copy of those parts of the document that relate to the collaborating provider’s treatment of the patient’s condition;
(v) offers a copy of the document to the patient and the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees);
(vi) adds a copy of the document to the patient’s medical records.
(2) For this clause, a collaborating provider is a person who:
(a) provides treatment or a service to a patient; and
(b) is not an unpaid care of the patient.
Now briefly, let’s look at principles of statutory interpretation, where the text, context and legislative purpose must be considered, as well as the plain English meaning of the words used.
The legislative purpose is to facilitate multidisciplinary patient care, but the overarching principle that Medicare is for patients not providers continues to apply and therefore the patient will ultimately decide whether to avail the multidisciplinary care on offer or not.
Key requirements relating to the other 2 care providers (also referred to as collaborating providers) are that:
- You must consult with them. AND
- You must arrange multidisciplinary care. AND
- You must prepare a document setting out certain things. AND
- You must give the other care providers a copy of relevant parts of your document.
- A collaborating provider is a person who provides treatment or a service to a patient. Note there is no compulsion that this person treats your patient, just that they treat or provide a service to patients generally.
Notably, the statute does not expressly require that the collaborating providers must formally accept your invitation to participate in the care of your patient.
Second – record keeping
Medicare is date of service (DOS) driven. Inclusion of the DOS on all Medicare claims is a regulated requirement. The regulated description of the DOS is “the date on which the service was rendered.” However, section 81(1) of the Health Insurance Act 1973 expands this description by addition of the word “initiation” as shown below (emphasis added):
“adequate and contemporaneous records of the rendering or initiation of services means records that meet the standards prescribed by the regulations for the purposes of this definition.”
Following on from this, the standard is prescribed in clause 6 of the Health Insurance (Professional Services Review Scheme) Regulations 2019. It is copied below. It also includes the concept of “initiating” a service:
“6 Standards for adequate and contemporaneous records
For the purposes of the definition of adequate and contemporaneous records in subsection 81(1) of the Act, the standards for a record of the rendering or initiation of services to a patient by a practitioner are that:
(a) the record must include the name of the patient; and
(b) the record must contain a separate entry for each attendance by the patient for a service; and
(c) each separate entry for a service must:
(i) include the date on which the service was rendered or initiated; and
(ii) provide sufficient clinical information to explain the service; and
(iii) be completed at the time, or as soon as practicable after, the service was rendered or initiated; and
(d) the record must be sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record.”
The concept of rendering or initiating services is particularly important in the context of the GP chronic disease management (CDM) services including TCAs.
While the definitions section of the Health Insurance (Professional Services Review Scheme) Regulations 2019 does not include a definition of “initiated”, quite a few Medicare services are initiated on one date but completed on another. For example, sleep studies are required to be initiated prior to midnight on day one but are not completed until the morning of day two. Common services provided in intensive care units are global – spanning a full day (so you can claim the service literally anytime on that day even before you have done anything to the patient) – and still other services, like some CDM services, can span days or even weeks such as the residential medication management review item 903.
In our experience date discrepancies are quite common for CDM services because of differing interpretations of when the service was rendered or initiated, and what must take place before the claim can legitimately be made. This question is a good example. The GP who submitted the question does not wait for a positive reply from collaborating providers before submitting a claim for item 723 but is aware that other GPs do.
The bottom line is that the question of which date is the correct DOS is not always clear and different GPs will bill these arrangements differently.
But returning to basic principles. As long as you comprehensively document all the things you did in compliance with the regulated requirements, including consulting with 2 collaborating providers, you can claim item 723. There is no requirement that the collaborators must actively accept, although it would obviously add credence to your consultation process if they did. In terms of what consulting means, there is no current legal definition. So, if you send text messages or make phone calls or have corridor conversations, write the details down immediately in your notes, sign, and date them.
Finally, as long as your service is clinically necessary and you have met all requirements, you can claim it. If you refer your patient to a specialist, you do not have to wait for the patient to see that specialist before claiming item 23 for example. They may never see the specialist. Once you have met the item 23 requirements, which may include writing a specialist referral, you can claim item 23. Similarly, when claiming item 723, as long as you have met all requirements you can claim it, noting that your patients may never access the allied health services you made available irrespective of whether your collaborating providers accepted your invitation or not.
And remember this always – if it wasn’t written down, it didn’t happen.
And this:
Good records = Good defence
Poor records = Poor defence
Bad records = No defence.
Examples and other relevant information
This GP asked several specific sub-questions. Here are the answers.
I have many patients who have been seeing a provider for many years (eg annual foot check for diabetes) and we have past correspondence from the provider. Does this fulfil the MBS criteria?
No, because Medicare is a fee-for-service system in which each service is distinct and finite. Just because a provider agreed to participate once does not mean they will always. The correspondence must relate to each specific service not a global arrangement. It is no different to global consent to bulk billing being illegal because it effectively creates an open cheque book, which is strictly prohibited.
Would verbal consent from a provider be adequate (e.g. for a provider working in our practice e.g. dietician)?
Yes. There is no specific requirement to have written agreement, but you should make a detailed file note of the conversation you had with the dietician, the time you had it and what was agreed. Remember, your clinical records will always be your best defence in an investigation.
Would it suffice to add a clause to each referral letter, something like “please advise me if you do not consent to being part of this patient’s chronic care team” and by implication there is consent unless they decline?
To put this in place you would need to first exchange signed correspondence with your referrers confirming they agree to this approach, and expressly state that they will inform you only if they do not agree. We view this approach as risky and do not recommend it because the risk of forgetting to regularly review the arrangements in the context of providers moving on, retiring, changing practices etc is too great.
Could we have preferred providers that we gain a written document for the whole practice in which they agree to be part of any of our patient chronic care team unless they specifically decline?
See above.
Who this applies to
All GPs able to claim Team Care Arrangement item 723.
When this applies
Always