Recent

Do the words “ongoing care” on a GP referral mean the referral is indefinite?

19 January 25

We have been informed that a GP re-referral for “ongoing care” where no duration is specified should be interpreted as an INDEFINITE REFERRAL. We do not think this is sufficient for something to be construed as being an indefinite referral, but instead would be 12 months if no duration is stated.

If we obtain verbal consent from the patient to bulk bill and note it in the patient’s file, is that compliant for bulk billing?

19 January 25

Is a verbal consent noted in the patient’s file enough? If a bulk billed patient has to provide consent by signature for items put through to Medicare this creates additional admin work, in particular for telehealth.

When a respiratory physician does a bronchial biopsy (item 38417) together with a radiologist doing the fluoroscopy why is one claim rejected?

12 January 25

We have a scenario where Medicare reject claims submitted by the physician for an item 38417 because it states fluoroscopy can only be claimed by one provider once for that occasion of service. The physician performs the bronchial biopsy and a radiologist performs the fluoroscopic imaging to guide the physician when taking the biopsy. In this case the doctor physician claimed a 38417. The radiologist claimed a category 5 diagnostic item group 13 MBS item and the radiologist claim was submitted prior to the physician lodging their claim. As stated by the physician, “38417 is the most correct item number for the procedure. The item description does say “with or without associated fluoroscopic imaging”. I performed the procedure described as MBS 38417 for an ultrasound biopsy and the radiologist performed and billed the fluoroscopy. “It does not seem right that the physician cannot claim the 38417 when by description the procedure fits exactly with this item.” When two providers need to partake in the provision of a service due to the particular areas of specialty (i.e. medical procedure v diagnostic imaging), what is the best approach when dealing with Medicare and the claim?

If I have to abandon a pulmonary vein isolation or pacemaker procedure part way through, can I still bill it to Medicare?

12 January 25

I occasionally have patients who come into hospital for a pulmonary vein isolation (item numbers 38290, 38212, 38206, 55118) but at the time of the procedure we find an intracardiac thrombus which means the case has to be abandoned. Is there a way to bill for abandoned pulmonary vein isolations? The same occasionally happens where a patient comes into hospital for a pacemaker implant (item numbers 38356, 38353, 61109) and I find that the veins are blocked or abnormal and not suitable for passing pacemaker wires into the heart. In these cases I have to abandon the procedure and rebook them for another time after further assessment and discussion with the patient. Is there a way to bill for abandoned pacemaker procedures as well?

Fraud, Waste and Abuse Monthly Round Up January 2025

6 January 25

Here’s a summary of PSR cases and other FWA activity PSR Case Reports November 2024 In the month of November 6 section 92 agreements and 2 final determinations came into effect. 5 of the agreements were made with GPs and 1 with an Oral and Maxillofacial Surgeon. 3 GPs were disqualified from billing certain items and/or prescribing certain medications for a period. The maximum repayment across all practitioners for November was $495,000, which was enforced against a GP who billed MBS items 23, 36 and 44 (level D consultation) and 66596 (iron studies) in excess of 99% of their peers. The findings against this GP included that the practitioner’s record keeping was inadequate, MBS requirements were not always met including minimum time requirements and there was no clinical indication for some of the iron studies. The Oral and Maxillofacial Surgeon was found to have inappropriately billed various procedures including local skin flaps, operations on the mandible or maxilla, reduction of maxillary tuberosities, wound debridement and trigeminal nerve blocks. The surgeon was required to repay $150,000, and was disqualified from claiming items 18234, 30023, 45815, 45829 for 3 months. The two final determinations were both against GPs. The first GP was found to have incorrectly billed services for patients at Residential Aged Care Facilities. This included inadequate history taking, inadequate records, missing entries for the dates of service billed, patients not needing urgent assessment when urgent items were billed and inadequate clinical input. The second GP was found to have incorrectly billed various skin lesion services including laser photocoagulation, skin flaps and...