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Referrals

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. 

4 November 24

I have a question regarding the validity of referrals sent via fax without a GP signature. All too frequently the GP gives the client the only signed hard copy and they either lose it or turn up without it. This leaves us chasing a referral. If the receptionist at the GP practice sends us a copy of the referral, they can only do so via fax without a GP signature. Current debate in the professional circles is underway again about whether a referral received via fax without a GP signature is indeed legal under Medicare. 

24 October 24

In the last 12 months or so, I’ve had repeated problems with referrals marked “indefinite” by the GP. These will be accepted by Medicare for some time, then randomly start getting rejected. Repeated phone calls to Medicare cannot provide an explanation. As a result, I am tempted to reject indefinite referrals – but GPs just see that as a self-serving request assuming I’m just doing it to increase my billings. An issue mostly for patients as they get very disgruntled when Medicare refuses their rebate, and since the event has occurred, they can’t get a new referral from their GP, since it would have to be backdated. An example was given: An inpatient ECLIPSE claim contained both a 116 and a 13918 on the same date of service, with a valid indefinite referral. Claims for this patient had previously been accepted without issue under the same referral. The 116 claim was rejected by Medicare, but the 13918 was paid. This makes me question whether 13918 and 13706 are item numbers that require a referral at all… Nothing in the item wording says they are a referred item number. Can you advise?

5 October 24

Obstetrician A is going overseas. Obstetrician A’s patients due for delivery while she is away will be looked after by Obstetrician B for antenatal visits billing 16500. Obstetrician B usually works in the same practice as Obstetrician A and sometimes sees Obstetrician A’s antenatal patients billing item 16500. Can Obstetrician B bill for a pregnancy management fee for those patients who are due while she is away using item 16591? Does this scenario qualify as shared caring?

30 September 24

I am a rehabilitation specialist working in a private hospital doing Day Rehab (patients are inpatients as they are admitted for the day). Usually, I see patients on the day they attend therapy (inpatient) however sometimes it is necessary to see them on another day (outpatient). I have access to their inpatient notes, but often there is not a formal referral (e.g., discharge summary states ‘For Day Rehab’). I have read a source that seems to suggest I don’t need a formal referral if I am billing them privately. However, I have read elsewhere that I need a valid referral for every patient (signed, dated, by a specialist or GP etc.). Which is correct?

30 September 24

I am working in a day rehabilitation setting at a private hospital (patients are admitted for the day for allied health interventions mostly after joint replacements and are inpatients when I see them). For patients who have come from an inpatient admission under another rehabilitation specialist, can I charge 110 when I first assess them, or would it be a 116?

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?

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?

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.

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.

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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