Public Hospital billing

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.

Can a nurse practitioner bill Medicare for public outpatients when the nurse practitioner is simultaneously being paid by a hospital that does not have a section 19(2) exemption?

30 September 24

I’m a Nurse Practitioner working in a small rural centre. I am a public employee 4 days a week and work privately on one day in the co-located primary health clinic/urgent care centre, which I bulk bill. A GP has left, and I have been asked to cover the clinic on two of my hospital days until a replacement is found. On these two days I am paid by the hospital as I still cover the emergency department. I have been asked to bulk bill the patients I see at the clinic on these two days even though I will be simultaneously being paid by the hospital. Both entities are wholly owned by the public health service, and it does not have a section 19(2) exemption. The GPs who work in the clinic are not employees of the public health service like me.

Should I bill an inpatient case conference or a community case conference when I organise and coordinate a case conference on a day when the patient is not admitted?

30 September 24

My question is regarding clarification of billing case conferences for day rehab patients. These patients are ‘admitted’ as inpatients on the day they attend. However, I perform the case conference with the team on a day they are not coming in for day rehab. For example, a patient may attend day rehab on Monday and Friday, but I do their case conference on a Wednesday when all the team members are present. Billing options: 880: inpatient case conference 825: community outpatient case conference. Up until this point I have been billing an 880 regardless of whether the patient has been admitted that day or not, but should I be billing an 825 instead? I don’t have a preference either way, but I think the 880 sounds more reasonable to me. Hopefully that makes sense but clarification around this would be great.

Do sessional Visiting Medical Officers have the same Rights of Private Practice as Salaried Medical Officers?

30 September 24

Is there the same concept of Rights to Private Practice for Sessional VMOs? We have not been able to locate any specific information on this combination. Essentially are we allowed to bill MBS for pain medicine consults under the Sessional VMO name (with referrals in place) and retain that billing to offset our costs? The facility was a public facility located in NSW.

Do I need a specific referral to admit the patient privately for every episode requiring admission?

27 September 24

No additional context was provided.

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?

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.

What constitutes a referral from the Emergency Department to an inpatient medical unit?

20 January 21

This is a common question. Who should the referrer be in these circumstances?

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?

In a public hospital outpatient clinic does a referral to “Dear Specialist” enable Medicare bulk billing?

21 September 20

Question: If a clinic receives a referral to “Dear specialist” can this be used by anyone in that practice? Or if it comes to a named specialist, can that validly be used by another provider in the same practice? These are privately referred non-inpatient in a public oncology setting that is bulk billed.

Can we bill to Medicare for public inpatients in public hospitals?

10 July 20

An administrator in a public hospital had been advised that they could start billing to Medicare for inpatient services including case conferences.

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Topics

Specialities

Public Hospital billing

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

Can a nurse practitioner bill Medicare for public outpatients when the nurse practitioner is simultaneously being paid by a hospital that does not have a section 19(2) exemption?

Should I bill an inpatient case conference or a community case conference when I organise and coordinate a case conference on a day when the patient is not admitted?

Do sessional Visiting Medical Officers have the same Rights of Private Practice as Salaried Medical Officers?

Do I need a specific referral to admit the patient privately for every episode requiring admission?

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?

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?

What constitutes a referral from the Emergency Department to an inpatient medical unit?

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?

In a public hospital outpatient clinic does a referral to “Dear Specialist” enable Medicare bulk billing?

Can we bill to Medicare for public inpatients in public hospitals?

Topics

Specialities

Public Hospital billing

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