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Rehabilitation Medicine

6 April 25

I am a rehabilitation physician that works in a private hospital that is offering a hospital substitution program for post joint replacement rehabilitation. Under the plan the surgeon will determine if the person is suitable for post joint replacement rehabilitation in the home and then the insurer pays the hospital to provide physio and occupational therapy services in the home. I have been asked to participate and offer medical governance through telehealth and case conferences to manage analgesia, blood thinning medications and to offer guidance re safe discharge from the program. Can I charge a no gap fee to the insurers for telehealth item numbers (91824 or 116) or do I have to visit people in their home (128 or 116) and can I charge for case conferences (is it 880 or 820)?

30 March 25

I am a rehabilitation physician that works at a public hospital that offers rehab in the home and hospital in the home for patients, as part of early discharge or hospital substitution strategies. If a patient chooses to use their private health insurance while in a public hospital for the purposes of a joint replacement and is then discharged home for rehab in the home as part of the hospital the hospital substitution scheme – Can I charge the insurer a gap payment for my home visit to them and what item number should I charge a 116 (in hospital follow up) or a 128 (follow as part of a home visit)?

10 March 25

I am hoping for some clarification around using the item number 55848 for ultrasound. Rehabilitation medicine physicians require ultrasound guidance for botulinum toxin injections. Assuming the ultrasound machine is appropriately accredited, are we allowed to bill this code for the use of the ultrasound machine in addition to the item numbers for the injections (18360)?

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?

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?

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.

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?

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.

28 January 21

Dr A was a rehabilitation physician who wanted to know if they could claim items 170, 171 and 172 for family meetings. Dr A understood that geriatricians and other physicians use these items in circumstances when the family meetings are not usual case conferences or MDT meetings with allied health practitioners.

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.

31 August 20

Doctor A worked in a public hospital outpatient department where they exercised a right of private practice. They thought that they were not automatically permitted to bill item 132 every 12 months but had received contrary advice. Further, they were unclear about whether item 133 applies twice in the first year only or twice every year. They had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean they could bill item 133 40 times.

26 August 20

Question: If the same treating rehab physician sees a patient following discharge in their outpatient rooms, can this be billed as a 132 (obviously with a relevant referral), or is it a 133/116 depending on other factors?  I’m just not clear if the inpatient and outpatient episodes are to be considered in isolation of each other.

27 July 20

When one physician covers anothers’ inpatients who have already been admitted, but are new to the doctor covering for the weekend, Dr A wanted to know if it is acceptable to bill a 110? Dr A’s instincts were that all encounters should be billed as 116 since they are generally part of the same episode of care, (even if provided by a different physician) but she had received conflicting advice.

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