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COVID MBS items Explainer and FAQs, No. 21, 6 April 2020

Dear Doctors and Health Care Workers

First some news. I am reliably informed that the reason today’s laws were not formally announced was because the forced bulk billing issue is still in discussion and further changes to the Determinations are imminent. This is a positive development. I spent a good amount of time wading through the Determinations today and there were a lot of baffling inconsistencies.

So, it seems likely the next round of changes may be announced as soon as tomorrow and we will see some lifting of the bulk billing restrictions for some practitioners, but the COVID services will likely continue for outpatients only. So not such great news for all the hospital based specialists out there.

We’ll update as soon as we know more tomorrow.

Here’s answers to today’s questions:

1.  (a) I am a physician who lives and works in regional Australia. For me to be able to bill patients with a gap using the standard (pre-COVID) telehealth item number 112 with a 110 or a 116 (rather than the bulk-billed COVID item numbers) is it true that the patient’s home address must be at least 15km from my place of work? 

Yes, you need to be 15kms from the patient, however, there are a few things to note:

Regulation 1.2.6(4)(3) provides that ‘personal attendance’ includes participating in a video conference consultation referred to in item 112, so this effectively provides that you satisfy the requirement to ‘personally attend’ even though the consult takes place via video.

The requirement is not 15kms from the patient’s home address, but rather, you and the patient just need to be 15km by road apart when the service is provided, but you cannot travel to a place to satisfy the 15km requirement, meaning you can’t manipulate the requirement. For example, you are 14 kms from the patient. It is not acceptable to jump in the car and drive an extra km away so you can claim. 

(b) Are there other important stipulations when billing using the pre- COVID telehealth item numbers instead of using the COVID telehealth/telephone item numbers? 

From a legal compliance perspective, you must continue to meet all usual Medicare billing requirements such as only billing for clinically relevant services, observing the continuous course of treatment rules, using the correct provider number, having a valid referral, keeping adequate and contemporaneous records, obtaining the patient signature if bulk billing and from a telehealth perspective, ensure you continue to meet relevant privacy and data security requirements.

2.  I had thought that to bill item 132 required an examination to be performed. So is it legal to bill a 132 for a telehealth consult, as even if the patient has multiple co-morbidities and is complex, you can’t do an examination (This also applies to COVID as I note that equivalent item numbers for 132 are expected to become available from tomorrow – item numbers 92422 and 92431).

See the above answer. You can bill an item 132 as telehealth by adding 112 (if all other criteria are met) because item 112 provides an override of sorts, which satisfies the ‘personal attendance’ requirement.

Also, the description of item 132 in the regulations doesn’t actually state that an examination is required. Here are the relevant parts copied for you, with my underlining:

“Professional attendance by a consultant physician in the practice of the consultant physician’s specialty (other than psychiatry) of at least 45 minutes in duration for an initial assessment of a patient with at least 2 morbidities (which may include complex congenital, developmental and behavioural disorders) following referral of the patient to the consultant physician by a referring practitioner, if:

(a) an assessment is undertaken that covers:

(i) a comprehensive history, including psychosocial history and medication review; and

(ii) comprehensive multi or detailed single organ system assessment; and

(iii) the formulation of differential diagnoses; and”

The issue is whether one can do a multi or detailed organ system assessment without physically examining the organ system. In the absence of a court determination on the issue, best advice is that the very fact that Medicare has enabled item 132 to be billed via telehealth is sufficient evidence that the department believes it is possible to do a detailed or multi organ system assessment via video.

This is a nuanced area of course and whilst your findings examining a patient may differ to those of a less experienced colleague, it would nonetheless seem prudent to have a nurse or GP at the patient end facilitating any necessary examination if possible.

3.  I understand rural telehealth can be privately billed so patients pay a gap. How does this work on an invoice when including item 112 with the original item number – is there a gap fee on both items? Eg: if the total out of pocket cost was to be $50 to the patient for example, could I just add $40 to the rebate amount of the consultation item number, and $10 to the rebate amount for the associated item 112?

There is no specific rule around this common dilemma. You could split the gap fee as you have suggested or just add the whole $50 to the base item 110 or 116 etc. It will make no difference to the patient rebate, so don’t stress about it too much.

4.  I am a specialist and there are two of us in the department. I understand GPs don’t have to refer to a named specialist for assessment and management (for the specialist to be able to bulk bill Medicare for the provided service). What if a patient requests a second opinion? Can the GP in that instance send a referral to a named specialist (the nearest specialist is 2.5 hours’ drive away) and patients prefer to be seen locally?

Good question. So, when a referral is activated, the doctor who picked it up and initiated an initial consultation using that referral has adopted it, if you like. So, by that, I mean, your colleague cannot then also undertake an initial consultation using the same referral, even if it is a second opinion.

The patient, unfortunately, will need to return to the GP and obtain another referral, which does not have to be named, because following Medicare’s current interpretation of the relevant law, the patient can take the referral to any doctor of the same specialty.

5.  I see that Psychologists can gap for services can Psychiatrists do this too?

I think you are referring to the new COVID services? Just sit tight for another day and we should have answers for you on this issue.

6.  Any update regarding palliative care?

No. ☹

7.  I am a Psychiatrist. Subgroup 9 phone services appear to have differentiated ‘not an admitted patient’ for item 91838 only. Does this mean 91837, 91839, 91840, 91841 is allowable for admitted patients? Also appears to have an increased rebate amount?

As per my initial comments, there is a lot of movement in this area and the Determinations are likely to change again in the next 24 hours, so sit tight. I can say however, that my understanding is that COVID services will remain exclusively outpatients at least in this next round of changes. We will check the rebates tomorrow as well.

8.  Any new item numbers or changes in the world of radiology?

No. ☹

9.  When bulk billing telehealth numbers to our patients can the item number 10990 also be billed for qualifying patients? Our practice is an oncology practice.

No. The bulk bill incentive items can only be claimed with unreferred services (GP and non-specialist services). As oncologists, your services are referred.

10.  I am a specialist surgeon & would like some clarification on how to bill my patients who have consultations done via telehealth, because I would like to charge my telehealth patients a gap fee for their consultation. What are my options in terms of billing them? If I use the COVID 19- telehealth billing item codes for consultation: ie: For initial consultation – using COVID code -91832 – We could charge $175 – SO GAP is $99. For review consult – using COVID code -91833 – We could charge $112.30- So GAP is $74.

How does the patient get their Medicare rebate, because we cannot do the rebate online?

This is unfortunately very complex. Can I suggest you review bulletin 1 and bulletin 6 for an overview of the law around the government’s attempt to force bulk billing and options available such as charging a private fee without a Medicare item number?

Or is it better to charge the patient the gap fee as a ‘non rebatable fee” & provide them with a receipt for their payment & then bill Medicare for 91832 or 91833?

No! Do not do this. It is illegal. It is illegal in both COVID and non-COVID times. You cannot ever bulk bill and charge a gap. You may like to tune into an RACP Pomegranate Health episode called ‘Billing in Byzantium’ where I explained and discussed this.

11.  Can I charge the patient an out of pocket fee and then provide an invoice for the patient to claim their rebate from Medicare. 

Yes and no. See the answer to question 10 above. We have heard that patients have been successfully receiving their rebates, but we have also more recently heard they have not (and have been complaining to Medicare which is good). But there is nothing to stop you charging your private fee. The issue is whether you choose to put a COVID item number on your invoice or no item number. See Bulletin 6.

12.  We are an oncology practice trying to unpack the new mandated telehealth bulk billing of all vulnerable patients. Pretty much all of our patients fit the vulnerable criteria i.e. immunosuppressed, suffering from a chronic health condition, often over 70. Can we continue to bypass all of this and just bill non-MBS private fees with no rebate, or has the government effectively legislated an environment where private patients can demand to be bulk billed?

It’s such a vexed issue isn’t it? But I am informed that one of the reasons the new laws enacted today were not announced, is because this issue needs more clarity. This is promising. But until that clarity comes and to be safe, I would probably just bill private fees and not use COVID (or any) item numbers.

Thanks everyone

Till tomorrow.

Margaret and the Synapse team.

COVID MBS items explainer and FAQs No. 22, 7 April 2020…Read more


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