If a public inpatient is discharged and then referred back to the hospital outpatient clinic by the GP (so, no previous Medicare billing), can I bill item 132 if I spend more than an hour with the patient?

Date of Answer: 1:29 pm  I  January 28, 2021

GA 2021/0127

Answer

No.

Context

A hospital billing manager asked: If we have a public inpatient that is discharged from the brain injury unit to the outpatient clinic for follow up (at this point no previous Medicare billing would have taken place as they were a public patient) and the GP writes a specific referral for the patient to see a specialist post inpatient discharge (different specialist from their inpatient stay).  The patient is seen in the outpatient clinic for > 1 hr.  Can we bill a 132, given that no previous billing has occurred?  The factors here are that the patient is referred to a new service by a GP; no previous 132 has been raised.

Relevant Legislative Provisions

Health Insurance Act 1973 (the Act), s. 3 and 10

Health Insurance Regulations 2018 (the Regs), reg. 50

Other Relevant Materials

The National Health Reform Agreement (NHRA)

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

MBS online (accessed 21 January 2021)

GN.14.34 Principles of interpretation of the MBS
Each professional service listed in the MBS is a complete medical service. Where a listed service is also a component of a more comprehensive service covered by another item, the benefit for the latter service will cover the former.

Detailed Reasoning

Medicare is a fee-for-service (FFS) scheme, which reimburses clinically relevant services exclusively. The legal definition of a clinically relevant service is below.

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.

Throughout the scheme, clinically relevant services are described as ‘professional services’. The relevant definition of a professional service is below.

professional service means: (a)  a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner…

Section 10 of the Act provides that when a professional service is provided to an eligible person, a Medicare benefit is payable in respect of that service. This is copied below.

Entitlement to Medicare benefit (1)  Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Regulation 50 of the Regs provides that the prescribed particulars must be sufficient to identify the item that specifies the service. It is also copied below.

All services—particulars of professional service rendered – General (1)  Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.

While this may all seem somewhat opaque, key points are:

1. The law consistently uses the singular ‘service’ and ‘benefit’ to link to the FFS structure of the scheme. Plurals are never used. This provides that each service is intended to have a start and end point on the date of service it is delivered.
2. When describing the service, there must be sufficient information to identify that the whole service was provided in accordance with its description. Note the department’s interpretation (above) which also confirms this position.

Business Rule G.17 (c) of the NHRA provides that referral pathways must not be controlled to require that a referral is a pre-requisite to receiving outpatient services at a public hospital. It is copied below.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:…
c. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

Applying the law to the facts described in the question:

1. There is no evidence that the referral pathway has been controlled or manipulated. The scenario describes a public patient being appropriately discharged back to the care of their GP and the GP making a decision to refer the patient back to the outpatient department for follow up specialist care, to a named medical specialist (noting the specialist MUST be exercising a Right of Private Practice). The referral described therefore appears to meet relevant referral requirements. See also GA 2020/0924
2. No previous claims to Medicare have been made because during the admitted episode of care the patient was public. There is therefore no barrier to claiming against the Medicare scheme.
3. The key issue for determination in this question is therefore less about the referral and more about very basic principles of compliant billing. Most notably, the law clearly provides that ALL elements of EVERY item number claimed must be met EVERY time you claim it – no exceptions.
4. The facts state that the doctor attending the patient at the first appointment in the outpatient department took over an hour. This fact alone DOES NOT meet the requirements of item 132, therefore it cannot be claimed in the circumstances described unless ALL other requirements of the item were also satisfied.
5. Key among the requirements of item 132 is the development of a detailed management plan (note the recent decision of the PSR above). It would be unlikely that the specialist would prepare a detailed management plan again, given one should have been prepared prior to the patient’s discharge from hospital.

If, and only if, the specialist meets ALL of the requirements of item 132 can the service be claimed in the circumstances described in this question. It would appear this would be unlikely given the recent discharge of the patient from the public hospital, but this is a matter for the specialist billing the service to decide.

Examples and other relevant information

This is Medicare billing 101 – you must never allocate item 132 just because the attendance took an hour or because it was your first consultation with the patient.

IMPORTANT: If the hospital bills the item 132 on behalf of the specialist in circumstances where the specialist is unaware this has happened, the hospital may be exposed to risk of sharing legal liability for the incorrect claim (should it be investigated) under Medicare’s shared debt recovery scheme.

You may like to watch this short HOW TO BILL video clip on the correct billing of items 132 and 133 (coming soon).

Who this applies to

All specialists exercising rights of private practice in public hospital outpatient departments who are eligible to claim items 132 and 133.

When this applies

Always

Relevant AIMAC courses

The Rules of Referrals – includes locum billing rules

Medical Billing in Public Hospitals

Understanding Medicare Compliance Audits

Date of Answer: 1:30 pm  I  January 28, 2021

GA 2021/0127

Answer

No.

Context

A hospital billing manager asked: If we have a public inpatient that is discharged from the brain injury unit to the outpatient clinic for follow up (at this point no previous Medicare billing would have taken place as they were a public patient) and the GP writes a specific referral for the patient to see a specialist post inpatient discharge (different specialist from their inpatient stay).  The patient is seen in the outpatient clinic for > 1 hr.  Can we bill a 132, given that no previous billing has occurred?  The factors here are that the patient is referred to a new service by a GP; no previous 132 has been raised.

Relevant Legislative Provisions

Health Insurance Act 1973 (the Act), s. 3 and 10

Health Insurance Regulations 2018 (the Regs), reg. 50

Other Relevant Materials

The National Health Reform Agreement (NHRA)

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

MBS online (accessed 21 January 2021)

GN.14.34 Principles of interpretation of the MBS
Each professional service listed in the MBS is a complete medical service. Where a listed service is also a component of a more comprehensive service covered by another item, the benefit for the latter service will cover the former.

Detailed Reasoning

Medicare is a fee-for-service (FFS) scheme, which reimburses clinically relevant services exclusively. The legal definition of a clinically relevant service is below.

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.

Throughout the scheme, clinically relevant services are described as ‘professional services’. The relevant definition of a professional service is below.

professional service means: (a)  a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner…

Section 10 of the Act provides that when a professional service is provided to an eligible person, a Medicare benefit is payable in respect of that service. This is copied below.

Entitlement to Medicare benefit (1)  Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Regulation 50 of the Regs provides that the prescribed particulars must be sufficient to identify the item that specifies the service. It is also copied below.

All services—particulars of professional service rendered – General (1)  Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.

While this may all seem somewhat opaque, key points are:

1. The law consistently uses the singular ‘service’ and ‘benefit’ to link to the FFS structure of the scheme. Plurals are never used. This provides that each service is intended to have a start and end point on the date of service it is delivered.
2. When describing the service, there must be sufficient information to identify that the whole service was provided in accordance with its description. Note the department’s interpretation (above) which also confirms this position.

Business Rule G.17 (c) of the NHRA provides that referral pathways must not be controlled to require that a referral is a pre-requisite to receiving outpatient services at a public hospital. It is copied below.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:…
c. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

Applying the law to the facts described in the question:

1. There is no evidence that the referral pathway has been controlled or manipulated. The scenario describes a public patient being appropriately discharged back to the care of their GP and the GP making a decision to refer the patient back to the outpatient department for follow up specialist care, to a named medical specialist (noting the specialist MUST be exercising a Right of Private Practice). The referral described therefore appears to meet relevant referral requirements. See also GA 2020/0924
2. No previous claims to Medicare have been made because during the admitted episode of care the patient was public. There is therefore no barrier to claiming against the Medicare scheme.
3. The key issue for determination in this question is therefore less about the referral and more about very basic principles of compliant billing. Most notably, the law clearly provides that ALL elements of EVERY item number claimed must be met EVERY time you claim it – no exceptions.
4. The facts state that the doctor attending the patient at the first appointment in the outpatient department took over an hour. This fact alone DOES NOT meet the requirements of item 132, therefore it cannot be claimed in the circumstances described unless ALL other requirements of the item were also satisfied.
5. Key among the requirements of item 132 is the development of a detailed management plan (note the recent decision of the PSR above). It would be unlikely that the specialist would prepare a detailed management plan again, given one should have been prepared prior to the patient’s discharge from hospital.

If, and only if, the specialist meets ALL of the requirements of item 132 can the service be claimed in the circumstances described in this question. It would appear this would be unlikely given the recent discharge of the patient from the public hospital, but this is a matter for the specialist billing the service to decide.

Examples and other relevant information

This is Medicare billing 101 – you must never allocate item 132 just because the attendance took an hour or because it was your first consultation with the patient.

IMPORTANT: If the hospital bills the item 132 on behalf of the specialist in circumstances where the specialist is unaware this has happened, the hospital may be exposed to risk of sharing legal liability for the incorrect claim (should it be investigated) under Medicare’s shared debt recovery scheme.

You may like to watch this short HOW TO BILL video clip on the correct billing of items 132 and 133 (coming soon).

Who this applies to

All specialists exercising rights of private practice in public hospital outpatient departments who are eligible to claim items 132 and 133.

When this applies

Always

Relevant AIMAC courses

The Rules of Referrals – includes locum billing rules

Medical Billing in Public Hospitals

Understanding Medicare Compliance Audits

Date of Answer: 5:33 pm  I  January 16, 2023

GA 2021/0127

Answer

No.

Context

A hospital billing manager asked: If we have a public inpatient that is discharged from the brain injury unit to the outpatient clinic for follow up (at this point no previous Medicare billing would have taken place as they were a public patient) and the GP writes a specific referral for the patient to see a specialist post inpatient discharge (different specialist from their inpatient stay).  The patient is seen in the outpatient clinic for > 1 hr.  Can we bill a 132, given that no previous billing has occurred?  The factors here are that the patient is referred to a new service by a GP; no previous 132 has been raised.

Relevant Legislative Provisions

Health Insurance Act 1973 (the Act), s. 3 and 10

Health Insurance Regulations 2018 (the Regs), reg. 50

Other Relevant Materials

The National Health Reform Agreement (NHRA)

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

MBS online (accessed 21 January 2021)

GN.14.34 Principles of interpretation of the MBS
Each professional service listed in the MBS is a complete medical service. Where a listed service is also a component of a more comprehensive service covered by another item, the benefit for the latter service will cover the former.

Detailed Reasoning

Medicare is a fee-for-service (FFS) scheme, which reimburses clinically relevant services exclusively. The legal definition of a clinically relevant service is below.

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.

Throughout the scheme, clinically relevant services are described as ‘professional services’. The relevant definition of a professional service is below.

professional service means: (a)  a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner…

Section 10 of the Act provides that when a professional service is provided to an eligible person, a Medicare benefit is payable in respect of that service. This is copied below.

Entitlement to Medicare benefit (1)  Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Regulation 50 of the Regs provides that the prescribed particulars must be sufficient to identify the item that specifies the service. It is also copied below.

All services—particulars of professional service rendered – General (1)  Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.

While this may all seem somewhat opaque, key points are:

1. The law consistently uses the singular ‘service’ and ‘benefit’ to link to the FFS structure of the scheme. Plurals are never used. This provides that each service is intended to have a start and end point on the date of service it is delivered.
2. When describing the service, there must be sufficient information to identify that the whole service was provided in accordance with its description. Note the department’s interpretation (above) which also confirms this position.

Business Rule G.17 (c) of the NHRA provides that referral pathways must not be controlled to require that a referral is a pre-requisite to receiving outpatient services at a public hospital. It is copied below.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:…
c. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

Applying the law to the facts described in the question:

1. There is no evidence that the referral pathway has been controlled or manipulated. The scenario describes a public patient being appropriately discharged back to the care of their GP and the GP making a decision to refer the patient back to the outpatient department for follow up specialist care, to a named medical specialist (noting the specialist MUST be exercising a Right of Private Practice). The referral described therefore appears to meet relevant referral requirements. See also GA 2020/0924
2. No previous claims to Medicare have been made because during the admitted episode of care the patient was public. There is therefore no barrier to claiming against the Medicare scheme.
3. The key issue for determination in this question is therefore less about the referral and more about very basic principles of compliant billing. Most notably, the law clearly provides that ALL elements of EVERY item number claimed must be met EVERY time you claim it – no exceptions.
4. The facts state that the doctor attending the patient at the first appointment in the outpatient department took over an hour. This fact alone DOES NOT meet the requirements of item 132, therefore it cannot be claimed in the circumstances described unless ALL other requirements of the item were also satisfied.
5. Key among the requirements of item 132 is the development of a detailed management plan (note the recent decision of the PSR above). It would be unlikely that the specialist would prepare a detailed management plan again, given one should have been prepared prior to the patient’s discharge from hospital.

If, and only if, the specialist meets ALL of the requirements of item 132 can the service be claimed in the circumstances described in this question. It would appear this would be unlikely given the recent discharge of the patient from the public hospital, but this is a matter for the specialist billing the service to decide.

Examples and other relevant information

This is Medicare billing 101 – you must never allocate item 132 just because the attendance took an hour or because it was your first consultation with the patient.

IMPORTANT: If the hospital bills the item 132 on behalf of the specialist in circumstances where the specialist is unaware this has happened, the hospital may be exposed to risk of sharing legal liability for the incorrect claim (should it be investigated) under Medicare’s shared debt recovery scheme.

You may like to watch this short HOW TO BILL video clip on the correct billing of items 132 and 133 (coming soon).

Who this applies to

All specialists exercising rights of private practice in public hospital outpatient departments who are eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 5:32 pm  I  March 1, 2023

GA 2021/0127

Answer

No.

Context

A hospital billing manager asked: If we have a public inpatient that is discharged from the brain injury unit to the outpatient clinic for follow up (at this point no previous Medicare billing would have taken place as they were a public patient) and the GP writes a specific referral for the patient to see a specialist post inpatient discharge (different specialist from their inpatient stay).  The patient is seen in the outpatient clinic for > 1 hr.  Can we bill a 132, given that no previous billing has occurred?  The factors here are that the patient is referred to a new service by a GP; no previous 132 has been raised.

Relevant Legislative Provisions

Health Insurance Act 1973 (the Act), s. 3 and 10

Health Insurance Regulations 2018 (the Regs), reg. 50

Other Relevant Materials

The National Health Reform Agreement (NHRA)

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

MBS online (accessed 21 January 2021)

GN.14.34 Principles of interpretation of the MBS
Each professional service listed in the MBS is a complete medical service. Where a listed service is also a component of a more comprehensive service covered by another item, the benefit for the latter service will cover the former.

Detailed Reasoning

Medicare is a fee-for-service (FFS) scheme, which reimburses clinically relevant services exclusively. The legal definition of a clinically relevant service is below.

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.

Throughout the scheme, clinically relevant services are described as ‘professional services’. The relevant definition of a professional service is below.

professional service means: (a)  a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner…

Section 10 of the Act provides that when a professional service is provided to an eligible person, a Medicare benefit is payable in respect of that service. This is copied below.

Entitlement to Medicare benefit (1)  Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Regulation 50 of the Regs provides that the prescribed particulars must be sufficient to identify the item that specifies the service. It is also copied below.

All services—particulars of professional service rendered – General (1)  Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.

While this may all seem somewhat opaque, key points are:

1. The law consistently uses the singular ‘service’ and ‘benefit’ to link to the FFS structure of the scheme. Plurals are never used. This provides that each service is intended to have a start and end point on the date of service it is delivered.
2. When describing the service, there must be sufficient information to identify that the whole service was provided in accordance with its description. Note the department’s interpretation (above) which also confirms this position.

Business Rule G.17 (c) of the NHRA provides that referral pathways must not be controlled to require that a referral is a pre-requisite to receiving outpatient services at a public hospital. It is copied below.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:…
c. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

Applying the law to the facts described in the question:

1. There is no evidence that the referral pathway has been controlled or manipulated. The scenario describes a public patient being appropriately discharged back to the care of their GP and the GP making a decision to refer the patient back to the outpatient department for follow up specialist care, to a named medical specialist (noting the specialist MUST be exercising a Right of Private Practice). The referral described therefore appears to meet relevant referral requirements. See also GA 2020/0924
2. No previous claims to Medicare have been made because during the admitted episode of care the patient was public. There is therefore no barrier to claiming against the Medicare scheme.
3. The key issue for determination in this question is therefore less about the referral and more about very basic principles of compliant billing. Most notably, the law clearly provides that ALL elements of EVERY item number claimed must be met EVERY time you claim it – no exceptions.
4. The facts state that the doctor attending the patient at the first appointment in the outpatient department took over an hour. This fact alone DOES NOT meet the requirements of item 132, therefore it cannot be claimed in the circumstances described unless ALL other requirements of the item were also satisfied.
5. Key among the requirements of item 132 is the development of a detailed management plan (note the recent decision of the PSR above). It would be unlikely that the specialist would prepare a detailed management plan again, given one should have been prepared prior to the patient’s discharge from hospital.

If, and only if, the specialist meets ALL of the requirements of item 132 can the service be claimed in the circumstances described in this question. It would appear this would be unlikely given the recent discharge of the patient from the public hospital, but this is a matter for the specialist billing the service to decide.

Examples and other relevant information

This is Medicare billing 101 – you must never allocate item 132 just because the attendance took an hour or because it was your first consultation with the patient.

IMPORTANT: If the hospital bills the item 132 on behalf of the specialist in circumstances where the specialist is unaware this has happened, the hospital may be exposed to risk of sharing legal liability for the incorrect claim (should it be investigated) under Medicare’s shared debt recovery scheme.

You may like to watch this short HOW TO BILL video clip on the correct billing of items 132 and 133 (coming soon).

Who this applies to

All specialists exercising rights of private practice in public hospital outpatient departments who are eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 4:45 pm  I  May 10, 2023

GA 2021/0127

Answer

No.

Context

A hospital billing manager asked: If we have a public inpatient that is discharged from the brain injury unit to the outpatient clinic for follow up (at this point no previous Medicare billing would have taken place as they were a public patient) and the GP writes a specific referral for the patient to see a specialist post inpatient discharge (different specialist from their inpatient stay).  The patient is seen in the outpatient clinic for > 1 hr.  Can we bill a 132, given that no previous billing has occurred?  The factors here are that the patient is referred to a new service by a GP; no previous 132 has been raised.

Relevant Legislative Provisions

Health Insurance Act 1973 (the Act), s. 3 and 10

Health Insurance Regulations 2018 (the Regs), reg. 50

Other Relevant Materials

The National Health Reform Agreement (NHRA)

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

MBS online (accessed 21 January 2021)

GN.14.34 Principles of interpretation of the MBS
Each professional service listed in the MBS is a complete medical service. Where a listed service is also a component of a more comprehensive service covered by another item, the benefit for the latter service will cover the former.

Detailed Reasoning

Medicare is a fee-for-service (FFS) scheme, which reimburses clinically relevant services exclusively. The legal definition of a clinically relevant service is below.

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.

Throughout the scheme, clinically relevant services are described as ‘professional services’. The relevant definition of a professional service is below.

professional service means: (a)  a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner…

Section 10 of the Act provides that when a professional service is provided to an eligible person, a Medicare benefit is payable in respect of that service. This is copied below.

Entitlement to Medicare benefit (1)  Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Regulation 50 of the Regs provides that the prescribed particulars must be sufficient to identify the item that specifies the service. It is also copied below.

All services—particulars of professional service rendered – General (1)  Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.

While this may all seem somewhat opaque, key points are:

1. The law consistently uses the singular ‘service’ and ‘benefit’ to link to the FFS structure of the scheme. Plurals are never used. This provides that each service is intended to have a start and end point on the date of service it is delivered.
2. When describing the service, there must be sufficient information to identify that the whole service was provided in accordance with its description. Note the department’s interpretation (above) which also confirms this position.

Business Rule G.17 (c) of the NHRA provides that referral pathways must not be controlled to require that a referral is a pre-requisite to receiving outpatient services at a public hospital. It is copied below.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:…
c. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

Applying the law to the facts described in the question:

1. There is no evidence that the referral pathway has been controlled or manipulated. The scenario describes a public patient being appropriately discharged back to the care of their GP and the GP making a decision to refer the patient back to the outpatient department for follow up specialist care, to a named medical specialist (noting the specialist MUST be exercising a Right of Private Practice). The referral described therefore appears to meet relevant referral requirements. See also GA 2020/0924
2. No previous claims to Medicare have been made because during the admitted episode of care the patient was public. There is therefore no barrier to claiming against the Medicare scheme.
3. The key issue for determination in this question is therefore less about the referral and more about very basic principles of compliant billing. Most notably, the law clearly provides that ALL elements of EVERY item number claimed must be met EVERY time you claim it – no exceptions.
4. The facts state that the doctor attending the patient at the first appointment in the outpatient department took over an hour. This fact alone DOES NOT meet the requirements of item 132, therefore it cannot be claimed in the circumstances described unless ALL other requirements of the item were also satisfied.
5. Key among the requirements of item 132 is the development of a detailed management plan (note the recent decision of the PSR above). It would be unlikely that the specialist would prepare a detailed management plan again, given one should have been prepared prior to the patient’s discharge from hospital.

If, and only if, the specialist meets ALL of the requirements of item 132 can the service be claimed in the circumstances described in this question. It would appear this would be unlikely given the recent discharge of the patient from the public hospital, but this is a matter for the specialist billing the service to decide.

Examples and other relevant information

This is Medicare billing 101 – you must never allocate item 132 just because the attendance took an hour or because it was your first consultation with the patient.

IMPORTANT: If the hospital bills the item 132 on behalf of the specialist in circumstances where the specialist is unaware this has happened, the hospital may be exposed to risk of sharing legal liability for the incorrect claim (should it be investigated) under Medicare’s shared debt recovery scheme.

You may like to watch this short HOW TO BILL video clip on the correct billing of items 132 and 133 (coming soon).

Who this applies to

All specialists exercising rights of private practice in public hospital outpatient departments who are eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 4:50 pm  I  May 10, 2023

GA 2021/0127

Answer

No.

Context

A hospital billing manager asked: If we have a public inpatient that is discharged from the brain injury unit to the outpatient clinic for follow up (at this point no previous Medicare billing would have taken place as they were a public patient) and the GP writes a specific referral for the patient to see a specialist post inpatient discharge (different specialist from their inpatient stay).  The patient is seen in the outpatient clinic for > 1 hr.  Can we bill a 132, given that no previous billing has occurred?  The factors here are that the patient is referred to a new service by a GP; no previous 132 has been raised.

Relevant Legislative Provisions

Health Insurance Act 1973 (the Act), s. 3 and 10

Health Insurance Regulations 2018 (the Regs), reg. 50

Other Relevant Materials

The National Health Reform Agreement (NHRA)

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

MBS online (accessed 21 January 2021)

GN.14.34 Principles of interpretation of the MBS
Each professional service listed in the MBS is a complete medical service. Where a listed service is also a component of a more comprehensive service covered by another item, the benefit for the latter service will cover the former.

Detailed Reasoning

Medicare is a fee-for-service (FFS) scheme, which reimburses clinically relevant services exclusively. The legal definition of a clinically relevant service is below.

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.

Throughout the scheme, clinically relevant services are described as ‘professional services’. The relevant definition of a professional service is below.

professional service means: (a)  a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner…

Section 10 of the Act provides that when a professional service is provided to an eligible person, a Medicare benefit is payable in respect of that service. This is copied below.

Entitlement to Medicare benefit (1)  Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Regulation 50 of the Regs provides that the prescribed particulars must be sufficient to identify the item that specifies the service. It is also copied below.

All services—particulars of professional service rendered – General (1)  Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.

While this may all seem somewhat opaque, key points are:

1. The law consistently uses the singular ‘service’ and ‘benefit’ to link to the FFS structure of the scheme. Plurals are never used. This provides that each service is intended to have a start and end point on the date of service it is delivered.
2. When describing the service, there must be sufficient information to identify that the whole service was provided in accordance with its description. Note the department’s interpretation (above) which also confirms this position.

Business Rule G.17 (c) of the NHRA provides that referral pathways must not be controlled to require that a referral is a pre-requisite to receiving outpatient services at a public hospital. It is copied below.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:…
c. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

Applying the law to the facts described in the question:

1. There is no evidence that the referral pathway has been controlled or manipulated. The scenario describes a public patient being appropriately discharged back to the care of their GP and the GP making a decision to refer the patient back to the outpatient department for follow up specialist care, to a named medical specialist (noting the specialist MUST be exercising a Right of Private Practice). The referral described therefore appears to meet relevant referral requirements. See also GA 2020/0924
2. No previous claims to Medicare have been made because during the admitted episode of care the patient was public. There is therefore no barrier to claiming against the Medicare scheme.
3. The key issue for determination in this question is therefore less about the referral and more about very basic principles of compliant billing. Most notably, the law clearly provides that ALL elements of EVERY item number claimed must be met EVERY time you claim it – no exceptions.
4. The facts state that the doctor attending the patient at the first appointment in the outpatient department took over an hour. This fact alone DOES NOT meet the requirements of item 132, therefore it cannot be claimed in the circumstances described unless ALL other requirements of the item were also satisfied.
5. Key among the requirements of item 132 is the development of a detailed management plan (note the recent decision of the PSR above). It would be unlikely that the specialist would prepare a detailed management plan again, given one should have been prepared prior to the patient’s discharge from hospital.

If, and only if, the specialist meets ALL of the requirements of item 132 can the service be claimed in the circumstances described in this question. It would appear this would be unlikely given the recent discharge of the patient from the public hospital, but this is a matter for the specialist billing the service to decide.

Examples and other relevant information

This is Medicare billing 101 – you must never allocate item 132 just because the attendance took an hour or because it was your first consultation with the patient.

IMPORTANT: If the hospital bills the item 132 on behalf of the specialist in circumstances where the specialist is unaware this has happened, the hospital may be exposed to risk of sharing legal liability for the incorrect claim (should it be investigated) under Medicare’s shared debt recovery scheme.

You may like to watch this short HOW TO BILL video clip on the correct billing of items 132 and 133 (coming soon).

Who this applies to

All specialists exercising rights of private practice in public hospital outpatient departments who are eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 4:50 pm  I  May 10, 2023

GA 2021/0127

Answer

No.

Context

A hospital billing manager asked: If we have a public inpatient that is discharged from the brain injury unit to the outpatient clinic for follow up (at this point no previous Medicare billing would have taken place as they were a public patient) and the GP writes a specific referral for the patient to see a specialist post inpatient discharge (different specialist from their inpatient stay).  The patient is seen in the outpatient clinic for > 1 hr.  Can we bill a 132, given that no previous billing has occurred?  The factors here are that the patient is referred to a new service by a GP; no previous 132 has been raised.

Relevant Legislative Provisions

Health Insurance Act 1973 (the Act), s. 3 and 10

Health Insurance Regulations 2018 (the Regs), reg. 50

Other Relevant Materials

The National Health Reform Agreement (NHRA)

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

MBS online (accessed 21 January 2021)

GN.14.34 Principles of interpretation of the MBS
Each professional service listed in the MBS is a complete medical service. Where a listed service is also a component of a more comprehensive service covered by another item, the benefit for the latter service will cover the former.

Detailed Reasoning

Medicare is a fee-for-service (FFS) scheme, which reimburses clinically relevant services exclusively. The legal definition of a clinically relevant service is below.

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.

Throughout the scheme, clinically relevant services are described as ‘professional services’. The relevant definition of a professional service is below.

professional service means: (a)  a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner…

Section 10 of the Act provides that when a professional service is provided to an eligible person, a Medicare benefit is payable in respect of that service. This is copied below.

Entitlement to Medicare benefit (1)  Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Regulation 50 of the Regs provides that the prescribed particulars must be sufficient to identify the item that specifies the service. It is also copied below.

All services—particulars of professional service rendered – General (1)  Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.

While this may all seem somewhat opaque, key points are:

1. The law consistently uses the singular ‘service’ and ‘benefit’ to link to the FFS structure of the scheme. Plurals are never used. This provides that each service is intended to have a start and end point on the date of service it is delivered.
2. When describing the service, there must be sufficient information to identify that the whole service was provided in accordance with its description. Note the department’s interpretation (above) which also confirms this position.

Business Rule G.17 (c) of the NHRA provides that referral pathways must not be controlled to require that a referral is a pre-requisite to receiving outpatient services at a public hospital. It is copied below.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:…
c. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

Applying the law to the facts described in the question:

1. There is no evidence that the referral pathway has been controlled or manipulated. The scenario describes a public patient being appropriately discharged back to the care of their GP and the GP making a decision to refer the patient back to the outpatient department for follow up specialist care, to a named medical specialist (noting the specialist MUST be exercising a Right of Private Practice). The referral described therefore appears to meet relevant referral requirements. See also GA 2020/0924
2. No previous claims to Medicare have been made because during the admitted episode of care the patient was public. There is therefore no barrier to claiming against the Medicare scheme.
3. The key issue for determination in this question is therefore less about the referral and more about very basic principles of compliant billing. Most notably, the law clearly provides that ALL elements of EVERY item number claimed must be met EVERY time you claim it – no exceptions.
4. The facts state that the doctor attending the patient at the first appointment in the outpatient department took over an hour. This fact alone DOES NOT meet the requirements of item 132, therefore it cannot be claimed in the circumstances described unless ALL other requirements of the item were also satisfied.
5. Key among the requirements of item 132 is the development of a detailed management plan (note the recent decision of the PSR above). It would be unlikely that the specialist would prepare a detailed management plan again, given one should have been prepared prior to the patient’s discharge from hospital.

If, and only if, the specialist meets ALL of the requirements of item 132 can the service be claimed in the circumstances described in this question. It would appear this would be unlikely given the recent discharge of the patient from the public hospital, but this is a matter for the specialist billing the service to decide.

Examples and other relevant information

This is Medicare billing 101 – you must never allocate item 132 just because the attendance took an hour or because it was your first consultation with the patient.

IMPORTANT: If the hospital bills the item 132 on behalf of the specialist in circumstances where the specialist is unaware this has happened, the hospital may be exposed to risk of sharing legal liability for the incorrect claim (should it be investigated) under Medicare’s shared debt recovery scheme.

You may like to watch this short HOW TO BILL video clip on the correct billing of items 132 and 133 (coming soon).

Who this applies to

All specialists exercising rights of private practice in public hospital outpatient departments who are eligible to claim items 132 and 133.

When this applies

Always

Date of Answer: 3:42 pm  I  May 15, 2023

GA 2021/0127

Answer

No.

Context

A hospital billing manager asked: If we have a public inpatient that is discharged from the brain injury unit to the outpatient clinic for follow up (at this point no previous Medicare billing would have taken place as they were a public patient) and the GP writes a specific referral for the patient to see a specialist post inpatient discharge (different specialist from their inpatient stay).  The patient is seen in the outpatient clinic for > 1 hr.  Can we bill a 132, given that no previous billing has occurred?  The factors here are that the patient is referred to a new service by a GP; no previous 132 has been raised.

Relevant Legislative Provisions

Health Insurance Act 1973 (the Act), s. 3 and 10

Health Insurance Regulations 2018 (the Regs), reg. 50

Other Relevant Materials

The National Health Reform Agreement (NHRA)

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

MBS online (accessed 21 January 2021)

GN.14.34 Principles of interpretation of the MBS
Each professional service listed in the MBS is a complete medical service. Where a listed service is also a component of a more comprehensive service covered by another item, the benefit for the latter service will cover the former.

Detailed Reasoning

Medicare is a fee-for-service (FFS) scheme, which reimburses clinically relevant services exclusively. The legal definition of a clinically relevant service is below.

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.

Throughout the scheme, clinically relevant services are described as ‘professional services’. The relevant definition of a professional service is below.

professional service means: (a)  a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner…

Section 10 of the Act provides that when a professional service is provided to an eligible person, a Medicare benefit is payable in respect of that service. This is copied below.

Entitlement to Medicare benefit (1)  Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Regulation 50 of the Regs provides that the prescribed particulars must be sufficient to identify the item that specifies the service. It is also copied below.

All services—particulars of professional service rendered – General (1)  Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.

While this may all seem somewhat opaque, key points are:

1. The law consistently uses the singular ‘service’ and ‘benefit’ to link to the FFS structure of the scheme. Plurals are never used. This provides that each service is intended to have a start and end point on the date of service it is delivered.
2. When describing the service, there must be sufficient information to identify that the whole service was provided in accordance with its description. Note the department’s interpretation (above) which also confirms this position.

Business Rule G.17 (c) of the NHRA provides that referral pathways must not be controlled to require that a referral is a pre-requisite to receiving outpatient services at a public hospital. It is copied below.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:…
c. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

Applying the law to the facts described in the question:

1. There is no evidence that the referral pathway has been controlled or manipulated. The scenario describes a public patient being appropriately discharged back to the care of their GP and the GP making a decision to refer the patient back to the outpatient department for follow up specialist care, to a named medical specialist (noting the specialist MUST be exercising a Right of Private Practice). The referral described therefore appears to meet relevant referral requirements. See also GA 2020/0924
2. No previous claims to Medicare have been made because during the admitted episode of care the patient was public. There is therefore no barrier to claiming against the Medicare scheme.
3. The key issue for determination in this question is therefore less about the referral and more about very basic principles of compliant billing. Most notably, the law clearly provides that ALL elements of EVERY item number claimed must be met EVERY time you claim it – no exceptions.
4. The facts state that the doctor attending the patient at the first appointment in the outpatient department took over an hour. This fact alone DOES NOT meet the requirements of item 132, therefore it cannot be claimed in the circumstances described unless ALL other requirements of the item were also satisfied.
5. Key among the requirements of item 132 is the development of a detailed management plan (note the recent decision of the PSR above). It would be unlikely that the specialist would prepare a detailed management plan again, given one should have been prepared prior to the patient’s discharge from hospital.

If, and only if, the specialist meets ALL of the requirements of item 132 can the service be claimed in the circumstances described in this question. It would appear this would be unlikely given the recent discharge of the patient from the public hospital, but this is a matter for the specialist billing the service to decide.

Examples and other relevant information

This is Medicare billing 101 – you must never allocate item 132 just because the attendance took an hour or because it was your first consultation with the patient.

IMPORTANT: If the hospital bills the item 132 on behalf of the specialist in circumstances where the specialist is unaware this has happened, the hospital may be exposed to risk of sharing legal liability for the incorrect claim (should it be investigated) under Medicare’s shared debt recovery scheme.

You may like to watch this short HOW TO BILL video clip on the correct billing of items 132 and 133 (coming soon).

Who this applies to

All specialists exercising rights of private practice in public hospital outpatient departments who are eligible to claim items 132 and 133.

When this applies

Always