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Public Hospital billing

7 July 25

Is the following correct? For item 13706, I was informed by askMBS that two items are generally paid in one day, as long as they are clearly indicated to be separate transfusion episodes – marked Not Duplicate Service and with relevant service text. The example would be a patient who comes into hospital anemic, receives a unit of blood in the morning, then has an upper GI bleed and requires further transfusions in the afternoon. Or someone who is pancytopenic and receives a blood transfusion in the morning, then requires platelets in the afternoon for an emergency procedure. As far as I can tell from the MBS description, the definition should not limit this item to once per day, which is usually clearly indicated in other cases. Medicare used to pay up to 3 or 4 items of 13706 per day but recently they have been rejecting anything beyond 2 items.

29 June 25

Can a request for diagnostic imaging in a public hospital be Medicare billed if: 1) appropriate GP referral to a named obstetrician has occurred 2) the patient has elected to be a no fee private patient for attendance in the antenatal clinic 3) request for ultrasound imaging is filled out by a registrar “on behalf of” a specialist with ROPP named on the request while attending the antenatal clinic 4) patient consents to be bulk billed for the scan Also, the NSW guideline states a request for imaging does not require a signature to be valid. Is that correct?

29 June 25

Would you kindly be able to confirm whether a Staff Specialist of a NSW Public hospital is eligible to register for participation in the Medical Gap Cover Scheme? I was under the impression that while they may be able to register, they are not eligible to be paid at the gap cover rate—only at the MBS rate. Could you please confirm the correct interpretation?

9 June 25

I am a fee for service VMO haematologist at a public hospital in Sydney. My head of department has indicated that we are not permitted to bill for inpatient blood product transfusions (eg: item 13703) for inpatients admitted to the hospital under our care (public or private). Apparently this directive has come from the hospital finance department. Is this correct? As haematologists, many  of our inpatients require blood product transfusions during their stay. I understand that we can only claim for a single transfusion item on a given day (as we would for a single chemo item 13950), but please could you clarify why we are not permitted to bill for transfusions at all when they are part of a treatment required for inpatient care?

12 May 25

Patients under ROPP in a Clinic must ‘elect’ for the duration of their referral according to our LHN guidelines. If they cannot ‘elect’ because of an absence of a named referral, we understand their ‘public’ status infect (for want of a better term) downstream requests and reports: e.g. Pathology in a public or private pathology system — YES: public e.g. Imaging in a public or private imaging service – YES: public e.g. PBS Scripts for outpatient treatment – NO: remains eligible for PBS if meet criterial However what about for other Procedures – Steroid injection by a Rheumatologist in outpatient public or private clinic (referred by name from Public clinic) – Flex-sig by a Gastroenterologist in a outpatient public or private clinic (referred by name form Public clinic) – Chemotherapy infusion by same Public oncologist self-referred to Public or Private chemotherapy infusion centre

24 March 25

On an internal referral written by a Specialist/ Physician does the patients GP details have to be written as per the Health Insurance Regs Section 99. As it is an internal referral the patient is already being treated in the same facility and would have already named their GP and have their GP recorded on their file.

3 March 25

If Doctor A writes a named referral to Doctor B from Doctor A’s private rooms to a public hospital outpatient clinic and through the triage process Doctor A is assigned the patient to treat in the public hospital outpatient clinic can MBS be claimed? Would the referral from the private rooms be able to be utilised in billing as the referring Doctor and treating Doctor are the same but have different provider numbers.

3 February 25

What happens to billing of a private patient in a public hospital who undergoes solid organ (other than kidney) transplantation? There is no MBS item billable for this so it can’t be billed to the patient’s private insurance, so can the hospital just change them back to public or does the patient have to be involved in that decision? Follow-up question asked. This updated context was provided. I think the situation is a bit more complex because it is not correct that patients are aware at the time of admission that they require a solid organ transplant, unless they are admitted to hospital from a transplant waiting list. A significant proportion of liver, heart, lung transplant patients are admitted to hospital with an infection, poisoning or trauma, that eventually leads to irrecoverable organ failure and a requirement for transplantation – sometimes months into the admission. If we follow the logic in your answer, anyone who has any chance of developing end stage organ failure that could be then eligible for a transplant should be admitted by default as public, which would be counterintuitive. So to be more specific, the question would be this: How should a hospital and clinicians approach a situation when a patient admitted with an acute condition (NOT previously on a transplant list) develops end stage organ failure and requires liver, heart, lung, etc transplantation during the course of their hospital admission (a good example would be a community acquired pneumonia or chest trauma leading into complicated...

17 November 24

This question relates to medical specialists exercising rights of private practice in public hospital outpatient departments. The questioner wanted to know if both Dr ABC and XYZ can use the referral in this context, given they are both named on it. In addition, the questioner had received advice that a “named referral” under the National Health Reform Agreement can only have one name on it, not two. The advice was that the referral had to have “a” name on it, and this was therefore an invalid referral. 

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.

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.

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.

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