Dear Doctors and Health Care Workers
It’s been quiet on the Covid billing front for a while which we hope means there is less confusion. However, quite a few questions have come in over the last week or so, most of which would be relevant to everyone. It’s quite a long read so settle in.
Here are the answers.
1. Can a GP bill for a telehealth consult and then if needed see the patient face to face and bill for a consultation on the same day. Are there restrictions and what would the process be?
Yes, this is permitted, though it is important to ensure this does not become a modus operandi. Covid telehealth items are not intended to enable triage of patients into your clinic, and two claims for every patient on the same day.
Think of the Covid attendance items like any other attendance items in the schedule. You can almost always claim two attendances on the same DOS (there are some exceptions such as 132 and 110) provided both are clinically relevant and one is not a continuation of the other. The regulations have always required that times be added to such claims. Times are the only additional legal requirement, however, in practice, you will usually also need to add the accepted acronym NDS (not duplicate services) to ensure your claims are paid. Here is the relevant section of the regs:
Regulation 59 of the Health Insurance Regulations 2018 provides (my underlining):
(1) This section applies if a medical practitioner, dental practitioner, optometrist, participating midwife or participating nurse practitioner attends a person more than once on the same day, and on each occasion:
(a) for a medical practitioner, dental practitioner or optometrist—renders a professional service specified in any of items 3 to 10948 of the general medical services table to the person; and
(b) for a participating midwife or participating nurse practitioner—renders a professional service specified in the general medical services table to the person.
Note: Some professional services are specified in a determination made under subsection 3C(1) of the Act.
(2) For each such professional service, a prescribed particular is the time at which the attendance started.”
A claiming tip is that you will need to submit both claims together if possible and both must have times and NDS added in the service text field.
If you submit the first one without a time or NDS, and then try to submit another claim later that day, your second claim will reject. It’s not always practical I know, but if you can hold off submitting claims till midnight or even the next day, this will give you time to amend any claims that need times and NDS added before they go.
IMPORTANT: If the second service is really a continuation of the first service then please read the answer to question 2 below.
2. If a doctor does a phone consult with a patient and it is deemed necessary that the patient needs to attend the clinic to be able to complete the consult, the patient then attends the clinic on the same day as the phone consult, can the doctor bill for phone and clinic visits? If not, can they bill for a longer consult? If they can bill for a long consult is it the telehealth item number or a 36?
Great question! See above answer to question 1 first.
The best guidance we have is not contained in the law, but in the MBS book, which states at AN.0.7:
“In some circumstances a subsequent attendance on the same day does in fact constitute a continuation of an earlier attendance. For example, a preliminary eye examination may be concluded with the instillation of a mydriatic and then an hour or so later eye refraction is undertaken. These sessions are regarded as being one attendance for benefit purposes. Further examples are the case of skin sensitivity testing, and the situation where a patient is issued a prescription for a vaccine and subsequently returns to the surgery for the injection.”
Even in non-Covid times this is not always clear cut as you all know, but Covid claiming has certainly compounded the challenge.
Best advice is to first make a clinical decision on whether the second consult is separate to the first or a continuation of the earlier consult. If the answer is that the second is a continuation of the earlier consult, then the two services are treated as one for Medicare purposes, and you should claim one attendance not two. Select the item which represents the total time you have spent attending the patient (such as 36) if you are a GP. Keep very good records here. Be clear and comprehensive – include statements like:
“This occurred during Covid. The patient called for a telehealth consult and I spent XX minutes on the phone dealing with A, B, C and D. I intended to bill Covid telehealth item XXX. However, it was necessary to physically examine the patient in relation to the same issue and so she came into the clinic where I spent another XX minutes doing X, Y and Z. The total time I spent actually attending the patient for the same condition was XX.”
You get the idea – write it all down.
As to the final point in your excellent question, there is absolutely no guidance at law as to whether you should select item 91801/91810 or 36 as your single item.
Best advice is to select the item that most accurately reflects the bulk of what happened. So, if you spent most of the time on the phone, but the patient came in just for a few minutes to check something, choose the relevant telehealth item. If on the other hand, the telehealth portion was short and you spent the bulk of the time F2F, select 36. If it’s evenly split, I would probably still select 36 to indicate to the department you had a F2F consult with the patient that day.
I cannot stress enough how important it is to write it down and spell out what happened comprehensively, not just the clinical matters but also in relation to billing.
3. I work for a Geriatrician. What are the current rules re: billing in nursing homes with Telehealth? Does it exist? It was my understanding that we can’t bill items 145,147, 128 over the phone in nursing homes. Is this still correct or do we have numbers equivalent that we can bill for consultations over the phone? I am getting mixed messages and would value your latest advice.
Your understanding was (and is) correct. Well done.
Items 122, 128, 145 and 147 all require F2F attendance.
Usual telehealth items for geriatricians are 141 and 143, with the associated telehealth item 149. But this is strictly video only. Do not claim them for phone attendances.
Have a look in Bulletin 22 for your Covid telehealth phone equivalents.
4. I have seen a patient using video conferencing and would normally just charge 92422 at my private rate. Afterwards I discovered that the patient was in a remote area and I could also charge 112. Can I bulk bill 112 and bill a 132 at my normal rate in two separate accounts?
No. If you have already billed the 92422 then it’s all over and our best advice is to stick with that and not go down the 6-month agonising path of trying to reverse and reissue claims.
Item 112 cannot ever be billed alone. It is just a telehealth loading item and must be co-claimed with another item such as 132. So, you need to either bulk bill both the 132 and the 112 or charge a private fee for both and the patient can claim back a rebate.
5. I am a geriatrician and did a long telehealth consult on a patient in late March this year when the only billing available was the 110 equivalent. Now she is coming into clinic to see me with a new referral and I’m wondering what can be billed- she would have ordinarily been a 132 or 141 for the first appointment but I guess I am stuck with a 116?
So, the starting point here is clinical relevance. Bill for the service you provide, never bill based on available rebates.
That said, there is no legal barrier to claiming the physician attendance items out of order. We often see physicians claim item 110, then 116’s then a later 132 and so on. We also see physicians claim item 116 and never claim a 110, because the first time they saw the patient was in a public hospital context and therefore the first private billable claim becomes a 116.
So, you are not necessarily ‘stuck’ with a 116 but as you know you cannot claim a 133 without a prior 132.
You have said you have a new referral, and whilst that does not necessarily permit the claiming of a new initial consultation, if the circumstances of the new referral include management of a new condition and it is clinically relevant to claim item 132 or 141, there is no legal barrier to claiming it.
Have a look at this answer on the MBS Answers website for more detailed information about the single course of treatment principle which applies here.
I hope that helps.
6. is WhatsApp an acceptable mode of video teleconferencing?
There are no strict rules around this, though you must adhere to privacy principles and data security.
7. I have a query about psychology item numbers. Since COVID I have been doing an increased number of short consults where appropriate using my clinical psychologist item numbers (91166, 91181). The clinical psychology numbers require a minimum of 30 minutes (30-50-minute duration required) which makes it stressful and unhealthy to see two people in an hour. Most of my consults are 50 minutes booked into a one-hour slot, starting routinely on the hour, giving me 10 mins refocusing and movement time at the end. The registered psychologist item numbers are 20-50 minutes – a 25-minute consult is more viable and healthier to see two people in an hour. When I log on to AHPRA it says I’m a Registered Psychologist (with endorsements). Any idea if it’s legal for a clinical psychologist to use “registered psychologist” item numbers (specifically 91169 telehealth and 91183 telephone)?
If I have understood correctly, you are seeking to do what might be described as down-coding. Am I right? You would actually prefer to claim the services available to psychologists even though you have higher qualifications, based on patient considerations.
I cannot answer this question definitively I am sorry because Medicare is so murky and mysterious, but it is usually ok to claim below what you are entitled to. For example, a physician who is entitled to claim item 110, can still claim the much lower paying and unreferred item 54 if she wants to for whatever reason.
I would suggest two things:
- A call to Medicare, and
- Submit a claim and see what happens. Sometimes it’s the only way to find out.
I’m sorry that’s not more definitive. It will likely depend on how you have been registered on Medicare’s system and the cross link to your AHPRA registration.
8. It is not uncommon that we encounter technical difficulties doing telehealth and have to adapt to a hybrid model. Sometimes we started on Video and had to abandon halfway through, and telephone the patient to complete the service. Other times there have been audio problems at the patient end and so we have stayed on video so we can see each other throughout but are actually taking over a separate phone call. How do we bill this?
This is a commonly reported problem, so you are not alone.
The law requires the following:
- If you are claiming a video consultation then both an audio and visual link must be maintained throughout, or
- If you are claiming a telephone consultation, only an audio link must be maintained throughout.
You will have to exercise discretion here and document well on a case by case basis. If you have maintained both an audio and visual link even though through two separate modalities, you have met the requirements. If in doubt, default to the lesser requirement of maintaining an audio link only.
Don’t forget to have a look at the new MBS Answers website at this link https://mbsanswers.com.au/ for answers to your non-Covid medical billing questions.
Margaret and the Synapse team.