General

Why are outpatient item numbers that attract 85% of the Medicare Schedule Fee not listed by the private health insurers?

3 October 24

The question was posed in the context of public hospital outpatient services where clinicians can bulk bill when exercising a Right of Private Practice providing all other criteria are met. The questioner wanted to know how they easily determine which item numbers should be claimed at 75% and which 85% because the Private Health Insurance (Benefit Requirement) Rules do not seem to include some MBS item numbers that are relevant to outpatient services and normally claimed at 85% of the schedule fee, such as telehealth and face-to-face consults, and the associated bulk bill incentives.

When bulk billing, is the patient’s agreement to assign their Medicare benefit required for all items or just the consultation items?

2 October 24

The questioner added that everything they had read talks about telehealth items only. Their understanding was that the assignment of benefit is only required for consultation items but not for other items. They gave the example of whether consent was required to bulk bill a 11714 ECG.

Can we charge facility fees to cover the cost of consumables when bulk billing?

30 September 24

A GP practice wanted to know how to “manage” facility fees for bulk billing patients. The question said that the practice needed to charge this fee to cover the cost of consumables, but the doctors also wanted to bulk bill and be able to claim the full bulk bill incentives. The practice is in a regional area where the bulk bill incentives are highest.

If a patient presents at a public hospital outpatient clinic with a named referral from their GP and needs admission but wants to go to a private hospital, is a new referral required?

27 September 24

If I see patients referred to me in the public clinic, and they are unwell and require admission to hospital at presentation to the clinic as patients with chronic disease sometimes are, do I need a separate referral from the referring GP or other senior doctor to admit them to the private hospital?

Is there a legal restriction to claiming a new initial day of ICU when the patient was discharged from ICU and readmitted within 3 days?

25 September 24

If a patient is discharged from ICU and readmitted within 3 days and we claim a new initial day of ICU management (13870), the claims reject. We find that if we resubmit the claim as item 13873 (subsequent day of ICU management), it is paid. However, this is not strictly a correct claim because the service provided best matches the initial day item 13870. Is there a legal barrier? The practitioner was also experiencing the same problems in relation to a number of other first and subsequent day services such as dialysis, haemofiltration and extracorporeal life support.

Can a fellow of the Australasian College for Emergency Medicine (FACEM) bill MBS codes outside of a private emergency department?

24 September 24

This FACEM was planning to open a walk-in emergency clinic similar to a GP urgent care centre. Importantly, this would not be an approved private emergency department (ED). The following scenarios were posed as part of the question. Scenario 1: A 68-year-old female presents to the treatment centre (FACEM lead) post fall and sustains a right wrist fracture & a laceration to her forehead. The patient is assessed by the FACEM which includes history, examination and organising investigations – some blood tests, ECG and X ray. As a part of treatment, the patient requires interpretation of an ECG, reduction of the fracture and application of plaster under a local block, and suturing of forehead laceration under local. Which code applies for the consult, is it 104 or 107? Which code applies for the fracture reduction and plaster application? Which code applies for the local block? Scenario 2: A patient presents with abdominal pain on a Sunday. The patient requires assessment by a FACEM, which includes, history, examination and organising investigations followed by treatment. Is seeing this patient on a Sunday considered an afterhours presentation? If yes, which code applies for the consult?

Can a podiatrist’s receptionist sign the acceptance of a GP referral?

24 September 24

When a podiatrist has received a referral from a GP to be involved in a coordinated care plan, can their receptionist sign the acceptance of the referral?

Do items 60506 and 60509 refer to surgical procedure time or fluoroscopy time?

23 September 24

No context was provided.

Do you have to withhold billing item 723 until a formal acceptance to participate is received from at least 2 care team members?

19 September 24

At our practice we do not hold the billing, and we charge item 723 on the same day as the GPMP (721). I have heard of other practices who withhold the 723 billing until signed faxes are exchanged with team care members so that it is all documented before charging.

Can a cardiologist self-refer to follow up a patient post discharge from hospital?

24 February 21

The question posed was: “Cardiologist, Dr Z, performs a procedure (permanent pacemaker implant) at hospital A (provider number 1), but would like to see the patient for ongoing care/follow up at practice B (provider number 2). Can Dr Z self-refer for the follow up visit?”

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?

28 January 21

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.

Can I take over a named referral in a public hospital outpatient setting if I am of the same specialty?

22 January 21

Doctor A was a rehabilitation physician working in a public hospital day rehabilitation unit. Prior to patients commencing the day rehab program (where they are admitted inpatients on each day they attend), they have an initial outpatient visit to determine their eligibility for the program. The referrals from the GPs always name one of the rehabilitation specialists. Doctor A wanted to know whether Doctor B could see the patient for the initial outpatient assessment even though the referral was to Doctor A.

Is there any way to charge only the gap and receive the Medicare rebate directly to our account rather than via a cheque sent to the patient?

20 January 21

The question asked was: Is there any way to do outpatient billings where the patient pays the gap only on the day, and then the clinic submits a claim for the unpaid Medicare rebate? Currently the patient pays us the gap only as cash on the day, and we need to then bill Medicare for the unpaid rebate. Medicare sends a cheque for the rebate amount to the patient, and they then have to send it to our practice. It takes a lot of time chasing the cheques. Is there was a way to get the cheques addressed to us rather than the patient such as by changing the billing address recorded at Medicare maybe? Also, can we get the 90-day cheque reimbursement from Medicare directed to us so we can follow up on rejected claims?

Can we obtain the patient’s signature to consent to bulk billing once, and use it for ongoing care?

20 January 21

The question posed was: Can the bulk bill “Assignment of Benefit” be specific to the hospital setting? We understand that patients sign this upon admission, and while it is not specific to any one doctor, it covers all the services rendered to the patient whilst in care.

Can I bill a private patient in a private hospital who was transferred from a public hospital, and who should the referral be from?

20 January 21

Dr A was unsure about correct referral pathways for patients transferred to a private hospital after an episode of care in a public hospital, and how such patients should be billed.

How do in-hospital referrals work?

20 January 21

A specialist doctor asked how the various specialists below should claim for their services in this very common scenario. Patient attends the Emergency Department (ED). The ED Dr refers the patient to Dr A and Dr B (of different specialties) for inpatient management of a complex presentation. Dr A performs an initial consultation and is then covered for a few days by Dr C. Dr B performs an initial consultation, which identifies another problem requiring the expertise of Dr D. At the end of the admission, there are outstanding specialist issues that require outpatient follow-up with Drs A and D. 1. Should all four specialists bill using the in-hospital override for all consultations? Can A, B and D all claim a 110 or 132 as reflective of the service they provided? 2. If C identifies a new issue that requires assessment and a change in treatment, can C claim an in-hospital 110 (non locum tenans)? 3. If A and D use an in-hospital override for inpatient claims, and then receive a subsequent Medicare-compliant referral for outpatient review of the issue(s) managed during the admission, does the outpatient review occur “after the end of the period of validity of the last referral to have application” (because the last referral expired at hospital discharge). If so, can they claim a 110?

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Topics

Specialities

General

Why are outpatient item numbers that attract 85% of the Medicare Schedule Fee not listed by the private health insurers?

When bulk billing, is the patient’s agreement to assign their Medicare benefit required for all items or just the consultation items?

Can we charge facility fees to cover the cost of consumables when bulk billing?

If a patient presents at a public hospital outpatient clinic with a named referral from their GP and needs admission but wants to go to a private hospital, is a new referral required?

Is there a legal restriction to claiming a new initial day of ICU when the patient was discharged from ICU and readmitted within 3 days?

Can a fellow of the Australasian College for Emergency Medicine (FACEM) bill MBS codes outside of a private emergency department?

Can a podiatrist’s receptionist sign the acceptance of a GP referral?

Do items 60506 and 60509 refer to surgical procedure time or fluoroscopy time?

Do you have to withhold billing item 723 until a formal acceptance to participate is received from at least 2 care team members?

Can a cardiologist self-refer to follow up a patient post discharge from hospital?

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?

Can I take over a named referral in a public hospital outpatient setting if I am of the same specialty?

Is there any way to charge only the gap and receive the Medicare rebate directly to our account rather than via a cheque sent to the patient?

Can we obtain the patient’s signature to consent to bulk billing once, and use it for ongoing care?

Can I bill a private patient in a private hospital who was transferred from a public hospital, and who should the referral be from?

How do in-hospital referrals work?

Topics

Specialities

General

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