Dear Doctors and Health Care Workers
Firstly, thank you all for your generous words of support in relation to these bulletins. It is the least we can do, putting our totally weird area of specialisation to use at a time when Medicare billing just got a whole lot more complex. We figure now is not the time for secret billing business because we are all in this together. So, it really is a pleasure doing this for you and making the information publicly available so it can be disseminated widely.
Before launching into today’s questions, it is apparent there is still confusion around signing the DB4 bulk bill voucher. So, what I thought I would do is a separate one pager just on that topic tomorrow and see if we can put the issue to rest. The law is (and has always been) very clear on signing bulk bill vouchers, but interpretation of the law is not. So, if you sent a question about this, we will answer it separately tomorrow.
Here’s answers to today’s questions:
1. I’m a Psychiatrist and conduct multidisciplinary case conferences.
a) Is it a legal requirement to write the start and end time?
No. There is no specific legal requirement to do this.
Medical record keeping is governed by legal requirements under two separate instruments, though the main instrument to be concerned with to answer your question is number 2 below:
- The Code of Conduct for Medical Practitioners in Australia, which you can access here https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx, and
- The Health Insurance Act 1973 (HIA) provides you must keep ‘adequate and contemporaneous’ records. The HIA cross references the Health Insurance (Professional Services Review Scheme) Regulations 2019, which provides the below definition of what constitutes an ‘adequate and contemporaneous’ record. You can access it here https://www.legislation.gov.au/Details/F2019L00180. Relevant section copied for you:
“Part 2—Prescribed matters for definitions
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.”
As you can see there is no specific requirement to record the start and end time of any consultation, including time-based consultations. Further, nothing has been added to the COVID Determination in this regard, however, read on.
b) Is software recording of duration acceptable eg Medical Director episode?
As per the response to point a), there is no legal requirement to record a start and finish time, but it is a good idea, nonetheless. If you were ever audited by Medicare, they would review your appointment schedule as a starting point to see how long your appointments were and whether the appointment times align with your claiming of time-based items. So, whilst not legally necessary it is a good habit to record start and finish times. Relying on software to do this is not recommended. What you write in the notes, rather than start and finish times auto populated by software, will be much more persuasive in an audit.
I always say to doctors – put yourself in the shoes of an administrative officer from Medicare who has been charged with auditing you. You want to have that boffin read the relevant entries in your records and think “right, well that looks like it would definitely have taken 40 minutes.”
The PSR Annual Reports have recorded prosecutions where the doctor billed item 36 (GP more than 20 minutes) and the corresponding record said only this “ISQ”. Needless to say, it didn’t end well!
2. How do I obtain consent for a case conference by patients who lack capacity to consent eg some people with intellectual disabilities? Can medical treatment decision makers give consent? If so, where is this stated, and do you have to complete and document a capacity assessment? If not, how can a case conference be provided?
This is an important question. However, it is a question about third party consent and capacity and not MBS billing. You are correct that the relevant psychiatry case conference item numbers require patient consent. There is a vast body of law in this area, which will intersect with Medicare requirements, and my best advice to you is to contact your MDO for further assistance.
3. I usually visit aged care facilities and use 145/147/122/128 item numbers. Now I wish to use telehealth – regardless of COVID 19 issues.
a) Can I still use these same item numbers on Telehealth?
No. You cannot use these items via telehealth. They all require face to face attendance.
b) In regards aged care facilities and telehealth, when can I use 149?
Item 149 is a usual Geriatrician telehealth loading item that you bill in conjunction with either item 141 or 143. But the patient has to be in a telehealth eligible area, which includes all residential aged care facilities. For example, the patient cannot be at home, and living around the corner from your practice.
4. I am a Nurse Practitioner and work in an organisation that provides sexual and reproductive health care. Over the last week I have been providing clients with the option of phone consultations allowing me to keep F2F consultations to a minimum and available for essential F2F services eg examinations and procedural contraception. With these phone consultations I have been privately billing women (who have consented to this prior & who have understood that they are NOT eligible under the MBS/COVID-19 MBS item numbers for rebates) and the billing receipt they receive does not have an MBS number on it. Some of these were new clients to our service.
Well done! All correct and compliant.
I understand that if an individual hasn’t been seen by the practitioner or service in the last 12 months that the Covid-19 item numbers are not to be used despite other vulnerable criteria being met?
This question has 2 parts:
- Firstly, the 12-month criteria do not apply to NP attendances, and
- Secondly, the ‘Vulnerable’ criteria no longer apply to any COVID services at all. This was completely scrapped from this morning.
If clients don’t fit the current MBS billing criteria is it acceptable to continue to privately bill these consenting clients, even in the case of eligible HCC holders? My experience so far is that clients have been willing to have a phone consultation and be privately billed and have been happy to pay knowing that the amount paid is not claimable under the MBS.
Yes, you can continue to do this for all patients at your discretion. Hopefully changes announced later this week will make it easier for you to bulk bill concession card holders and under 16s.
For many clients they can now just attend as a one-off visit for their F2F consultation eg procedural contraception and claim their usual MBS rebate from this visit.
Correct again. If your patients can continue to attend their face to face appointments, then bill your usual item numbers and fees as you always have.
5. Can we use COVID telehealth GP item numbers for residential care patients?
Yes. There is nothing in the Determination to suggest you cannot use your usual items 3/91790, 23/91800, 36/91801 and 44/91802 COVID equivalents for your patients who live in residential aged care facilities. The Determination was intended as a ‘whole of population’ solution, making telehealth and phone services available to ‘all Australians’, including those living in aged care.
For Medicare purposes, residential aged care facilities are ‘outpatient’ facilities because they are the patients’ ‘home’ not a ‘hospital.’ So, services provided in these facilities are always ‘non-admitted’ and therefore meet the COVID telehealth criteria.
6. I am Geriatrician. Is there a telephone / telehealth consultation COVID item number for 141 or 143? It is not financially viable to use item 110 for our initial consultations as we spend an hour with the patient.
No, there are no equivalents for items 141 and 143 at this time. I know this is challenging. We hope to see changes when Stage 5 is announced.
7. Have there been any changes to face to face consultations for 141, 143, 145, 147, 132 and 133?
No. See above point 5.
8. I am predominantly a public hospital specialist. I had a modest private practice which has collapsed completely because all elective procedures in private hospitals have ceased. I am on a register of volunteers to help at various private hospital if required. If I am called up to work in a private hospital caring for COVID cases, what provisions have been made?
I am sorry to hear of your challenges. Right now, all inpatient services remain completely excluded from COVID MBS billing. So, no provisions have been made insofar as MBS billing is concerned. The current expectation is that hospital-based practice will continue face to face, though this flies in the face of social distancing. We hope Stage 5 will bring necessary change.
9. I am a Psychiatrist. Do we use existing COVID item no’s for bulk billing for our usual billing or new ones will be provided?
Other than some new Psychiatry items for eating disorders, the COVID psychiatry items did not change in Stage 4. So, keep using the existing COVID psychiatry items – 91827 through 91840
10. We are a surgical practice which requires face-to-face consults, i.e. lesions, breast mass etc. We are already practicing social distancing, limiting patients, cleaning constantly and have reduced staff. Is there anything else l should be doing and are specialist allowed to keep consulting when teleconferencing & over the phone consults aren’t appropriate?
Completely understand your challenges and you sound like you are doing a brilliant job and should be applauded. Well done.
Yes, you can continue to bring patients in for face to face consults and bill as usual if telehealth or phone are not appropriate.
10. I am a Geriatrician and have patients booked to see me in my rooms who cannot attend due to COVID restrictions. I usually use item 141 on new comprehensive patients (was 149 on telehealth). Can I still do that? Or do I have to use item 110?
Have to use 110 COVID equivalent – 91824/34
11. As a Specialist, do I
a) Still need a referral for COVID19 telehealth items? and
b) Is there a time limit on how long appointments should be?
12. Do psychiatry items force us to still bulk bill under COVID 19 or can we use telehealth items irrespective of distance and rurality? If so, essentially the Government is forcing us to continue doing face to face contact to keep our practices viable?
Yes, the attempted forced bulk billing remains in place though it has been moved up into the General Provisions of the Determination, whereas before it was included at the item number level. By that I mean, before, each item number description included the words ‘and the service is bulk billed’. It doesn’t anymore. This is significant to the extent that it doesn’t force the issue quite as much, and as we explained in Bulletins 1 and 6, there is a big legal question mark over this whole bulk billing issue.
My understanding is that there will be relaxing of this potentially unenforceable requirement later in the week. But until then, yes it can be said you are being forced to continue face to face therapy to remain viable.
Lobbying via the RANZCP would be worth considering.
13. I am an obstetrician/gynaecologist. What are the restrictions for phone consultations for specialists?
14. Re Specialist COVID MBS item numbers for telephone consults. Is my interpretation correct that all patients with a valid referral can avail of BB telephone/ video consults, and are no longer restricted to ‘vulnerable individuals’?
15. It appears from the information I have read that you don’t need to have seen a client previously to use the COVID Telehealth item numbers? The previous determination required a F2F in previous 12 months.
Yes, correct. The 12-month requirement has been scrapped, though there are some restrictions on various care plans, so please send details of specific item numbers.
16. Which videoconferencing software platforms are deemed secure?
Good question. The best information we can provide is this, copied from the MBS Online fact sheets and available at this link http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-TempBB:
“Videoconference services are the preferred approach for substituting a face-to-face consultation. However, in response to the COVID-19 pandemic, providers will also be able to offer audio-only services via telephone if video is not available. There are separate items available for the audio-only services. No specific equipment is required to provide Medicare-compliant telehealth services. Services can be provided through widely available video calling apps and software such as Zoom, Skype, FaceTime, Duo, GoToMeeting and others. Free versions of these applications (i.e. non-commercial versions) may not meet applicable laws for security and privacy. Practitioners must ensure that their chosen telecommunications solution meets their clinical requirements and satisfies privacy laws.”
For more on privacy requirements please visit the Office of the information Commissioner at this link https://www.oaic.gov.au/
17. It is likely that I will be doing a telehealth consult with a nurse or nurse practitioner (NP) with the patient? What item numbers can the NP charge Medicare as part of this consultation?
It depends. Lots of questions here. Are you billing COVID items or usual telehealth items? Is the patient in a telehealth eligible area? If you are able to provide more detail as to the item number you plan to charge we can go from there.
18. I am a Psychologist. Can I now bulk bill pre-existing clients for phone/telehealth sessions who are not at risk of COVID but who are self-isolating and prefer not to attend face-to-face consultations?
Yes, you can.
19. We are a group of specialists and telehealth BB has slashed our income significantly, so we had to stand down staff and the rest of the staff are having to deal with the increased workload. It just does not work in private specialist practice. Are we able to bill like usual?
I know. This is hard. But the answer is no, you cannot bill ‘like usual’ if you are not seeing patients face to face. You can, however, charge private fees without an MBS item number if this is an option. See Bulletin 6. Hopefully the changes we need will be announced in Stage 5.
Please tell your doctors to lobby their specialist colleges.
20. I am a geriatrician. I know I cannot bill 141 via videoconferencing, In addition, most of my older patients are not technical enough to manage the videoconferencing, I am considering bring my patient in my clinic but put them in a separate room. I will set up the video devices for them. In that case, they are in my clinic, most of the consultation will be via videos, some I will do face to face. That will minimise the face to face contact. Do you think I can bill 141 for that in that set up?
Firstly, let me just say how much I love your ingenuity. Great thinking outside the box!
Your proposed model aligns with a Medicare ‘rule’ that you do not always have to be present for the entire consultation, even though personal, physical, face to face component is almost always required. Further, item 141 has the following specific content:
“Some of the information collection component of the assessment may be rendered by a nurse or other assistant in accordance with accepted medical practice, acting under the supervision of the geriatrician. The remaining components of the assessment and development of the management plan must include a personal attendance by the geriatrician.”
It is anticipated that item 141 may involve input of others such as a nurse. Given this, as long as you keep thorough ‘adequate and contemporaneous’ records and are physically in the room with the patient for some of the one hour period, then I am comfortable this would meet the relevant requirements.
21. Is there a COVID item for Geriatrician reviews or new patients?
No. Items 110 and 116 are all we have for now.
22. I have new patient referred to me and the initial consultation will be by phone. They will later need examination in-rooms, when they can safely attend. If I bulk-bill 91832 for phone initial attendance now, is only 105 claimable when the in-rooms consultation can occur? Or can I still bill 104?
The continuous course of treatment rule applies, so when you see the patient in your rooms you should bill 105.
Thank you everyone. Till tomorrow. Stay safe!
Margaret and the Synapse team.