Working together to get it right
Providing a quality service
through appropriate use of
Medicare
AGPAL, Melbourne, 19 April 2008
Dr Robert Menz & Dr Dilip Dhupelia
Senior Medical Advisers, Program Review Division
Overview
• Introduction – Quality though Compliance
• Scenarios and discussion with focus on:
1.
2.
3.
4.
Attendances
Chronic Disease Management
Mental Health Care
Skin Care
• Question time
What is compliance
• Ensuring the correct benefit is paid to
• an eligible patient for
• the correct service by
• an eligible practitioner.
• Service acceptable to majority of peers
• Role of DoHA and Medicare Australia
• Critical importance of good clinical records
• Need for good practice systems
• Quality clinical service related to quality compliance
Compliance philosophy
Fraud and deliberate noncompliance
Enforce
Criminal Prosecution
Opportunistic noncompliance
Deter
Practitioner Review
Program
Accidental noncompliance
Help
Targeted Feedback
Compliance
Support
Education
Attendance
Eligibility for certain services for Medicare
rebates (and some services that do not attract
rebates).
Itemisation for urgent and after hours
attendances.
Itemisation for some procedures.
Which item number (if any) can a GP bill for the
following services when provided by a practice
nurse or Aboriginal Health Worker?
Q.
Immunisation services. = 10993
Q.
Information collection regarding health
assessments/checks. = No item
Q.
Examining patient records to identify eligible patients
for EPC services. = No item
Providing wound management services (other than
normal aftercare). = 10996
Providing ongoing support and monitoring for patients
with chronic disease. = 10997
Q.
Q.
Yes or No? Can an account be raised for
Medicare purposes for the following services?
Q.
Q.
A medical examination to obtain or renew a driver’s
licence to drive a private motor vehicle, for reason of
age or medical condition. Yes
Examinations for entrance to educational
establishments. No
Q.
A medical examination required to claim eligibility
for certain Social Security benefits or
allowances.
Yes
Q.
Provision of medical advice over the phone in
emergency situations. No
Yes or No? Can an account be raised for
Medicare purposes for the following services?
Q.
Administering immunisations to year 10 students
at the local school. No
Q.
A medical examination to adopt or foster children. Yes
Q.
A medical examination/clearance to be able to
take up boxing as a sport.
No
Q.
Writing a report for one of your patients for life
No
insurance purposes.
Attendances
Working in a remote Aboriginal Medical Service. Each patient
is booked for 30 minute appointment and will all have spent 30
minutes with the Aboriginal Health Worker or Remote Area
Nurse. Consults usually involve exhaustive history,
comprehensive examination of multiple systems and
implementing a management plan.
Q. Your usual itemisation for these consults should be:
a) Item 23 because you are concerned that Medicare will
“audit” you for having too many item 36s No
b) Item 36 because the time and complexity are appropriate
for Item 36 Yes
c) Item 44 because the complexity meets the item descriptor
for Item 44, and with the time already spent by the AHW
or RAN, the time is more than 40 minutes No
Urgent AH Attendances
It is Sunday afternoon and you have been called to a family to
see two ill children. You correctly bill item 1 for the first
patient.
Q. Which item do you use for the second patient (assuming
less than 20 minutes)?
a) Item 1
b) Item 24
c) Item 5020
d) Item 5023/1
e) Item 5023/2
Item 5023/1
Urgent AH Attendances
It is 3am and you have been called by a family to see two
very ill children. You meet them at your consulting rooms. You
correctly bill Item 602 for the first patient.
Q. Which item do you use for the second patient (assuming
less than 20 minutes)?
a) Item 2
b) Item 23
c) Item 602
d) Item 5020
Item 5020
Questions?
Key Points for attendances
Ensure any Medicare claims are for clinically relevant
medical services
Ensure that the item descriptor is met for any item
For items with several components ensure that each
component is completed before submitting Medicare claim.
When uncertain about Medicare itemisation, after checking
the MBS, contact Medicare Australia on 132 150.
Chronic Disease Management
Patient eligibility for GPMP/TCA
Documentation requirements for CDM items
The meaning of collaboration
Mrs Jones
• 67 year old patient
• progressive osteoarthritis (OA) in her left knee for five years
• She can walk two km on flat surfaces but has
trouble climbing stairs
• She regularly takes modified release 665 mg
paracetamol, and occasionally takes courses
of Cox-2 inhibitors
• Hypertension well controlled
• Non smoker
• BMI of 26
She would like to discuss conservative management of her OA
and is interested in physiotherapy assessment and treatment.
Mrs Jones
Q. Is Mrs Jones eligible for a GP management plan (GPMP)
(Medicare item 721)?
Yes
Chronic medical condition (osteoarthritis) which would benefit
from a structured approach. (A30.12)
Mrs Jones
Q. Is Mrs Jones eligible for a team care arrangement
(TCA)?
No
TCA requires a team of at least two other providers who will
be providing ongoing treatment or services and this case
there is only one other provider (ie the physio)(MBS A.30.16)
Mrs Jones
Last month Mrs Jones travelled interstate. She ran out of
her Cox-2 medicine and visited her daughter’s GP just for a
prescription. The GP was keen to also prepare a GPMP and
billed MBS Item 23 and Item 721.
Q.
Is this appropriate?
No
• The GPMP should be billed by the usual GP (A.30.12 and A30.43)
• An attendance item should only be billed if the patient has a
condition (other than preparation of GPMP) that requires immediate
treatment. (A.30.46)
Mr Smith
• 58 years old
• Medical history
• Diabetes
• Hypertension
• Hypercholesterolaemia
• Gout
• COPD
• Reformed smoker
• Heavy drinker
• Medication:
• Metformin 850 BD
• Rosiglitazone 4 mg
• Ramipril 5 mg
• Atorvastatin 40 mg
• Aspirin 75 mg
• Allopurinol 300 mg daily
• Examination:
• BMI 31
• BP 155/90
• poor peripheral pulses
Mr Smith
Investigations:
• HbA1c 8.4
• Chol 6.3 9
• HDL 0.9
•
•
•
Does not attend regularly.
Has attended today for a check-up and
repeat prescriptions.
Concern about his medication adherence
Q. Is Mr Smith eligible for GPMP and TCA?
Yes
Mr Smith
Q. Who might be involved in the team care arrangements
(TCA)?
There is no right answer
Could include diabetes educator, dietician, exercise
physiologist, podiatrist, respiratory nurse endocrinologist,
psychologist, cardiologist, ophthalmologist
Mr Smith
Q. Is Mr Smith eligible for referral for assessment for group
allied health services?
Yes
Once Medicare has paid rebate for MBS item 721 or 725 (or
item 731 for RACF patients) for a patient with type 2
Diabetes. (M.9)
Mr Smith
You are completing TCA documentation and sent referral
letters to the Allied Health Providers involved in Mr Smith’s
ongoing care. You have not yet had a response from one of
them.
Q. Can you now bill Item 723?
No
Documentation for TCA requires collaboration with the other
participating providers and recording the treatment and/or
services that they have agreed to provide. Collaboration must
be based on two way communication.(A.30.19)
Mr Smith
Now have feedback from the other collaborating providers so
requirements for claiming Item 723 are fulfilled. Note that he
has completed all the requirements for the cycle of care. You
claimed Item 2517 (diabetes SIP) 12 months ago.
Q. Can you claim Item 2517 again today in association
with Item 723?
Yes
The cycle of care relates to past activity and the TCA is about future activity.
However for the same reason doctors can not claim item 725 or 727 (the review
items for GPMP and TCA) in association with the SIP annual cycle of care item.
The diabetes incentive items are payable 11 months after the previous claim.
Mr Smith
Q. Is he eligible for a Domiciliary Medication Management
Review (DMMR) (also called Home Medicine Review)
(Item 900)?
Yes
He is at risk of misusing his medication. He is on 6 regular
medicines and you are concerned about his medication
adherence (A.36.4)
Mr Smith
The DMMR includes the following steps:
1. assessing a patient's medication management needs
2. referring the patient to a community pharmacy for a DMMR,
and providing relevant clinical information required for the
review, with the patient's consent
3. discussing results with the reviewing pharmacist including
medication management strategies, and
4. developing a written medication management plan
following discussion with the patient.
Q. At which stage should the GP claim Item 900 (after step 1,
2, 3 or 4)?
Step 4
Questions?
Key points for CDM
• Used well, these procedures can lead to improved patient
outcomes
• Include patient goals in GPMP
• Include quantitative and qualitative targets in GPMP
• High quality CDM requires patient review - remember to
include the review date (and have system for recall)
• Document treatment and services that other team members
have agreed to provide, following two way collaboration
• Attendance with CDM items only if patient’s condition
requires immediate treatment
• If in doubt check the Medicare Benefits schedule or phone
132 150
Mental Health
• Better Access Mental Health initiative
• Medicare item numbers
• Community access to mental health professionals and
team-based care
• GP collaboration with psychiatrists, psychologists,
occupational therapists and social workers
• Better understand Medicare Australia requirements
and your responsibilities.
Mental Health Care Items for
General Practitioners
• Preparation of a GP Mental Health Care Plan (Medicare
Item 2710)
• Review of a GP Mental Health Care Plan (Medicare Item
2712)
• GP Mental Health Care Consultation (Medicare Item
2713)
Basic flowchart
Patient need identified
GP MHC Plan developed
(incl assessment and plan)
How does this work for
GPs?
Referral options may include:
-Psychiatrist
-Clinical psychologist
-Allied mental health provider
Patient referred for 6 services
(if required)
GP reviews need for services.
Referral for further 6 services
(if required)
GP MHC Consultation
(as required)
GP MHC Plan Review
(may incl review of referral
needs) (4 wks to 6 mths)
Ongoing patient management
Annie
• 21 years old long term patient
• low self esteem and previous depression
• attends frequently with non specific physical
complaints and sadness, worse over the last
three months
• difficult to make progress and resolve
her problems
• presents today to you very tearful and upset
because she has lost her job
Annie
Q. What Medicare item applies to this consultation?
One appropriate for time, complexity and content
of the consultation
Eg Could be any of items 23, 36, 44 or 2713
Q. Does a GP have to have a GP Mental Health Care Plan
(Item 2710) in place before Item 2713 can be used?
No
Annie
Q. Do GPs need mental health training to use the mental
health consultation item (item 2713)?
No
A.40.5. Although it is not mandatory, it is strongly recommended that GPs
providing mental health care using the new GP mental Health Care items
have completed appropriate mental health training, such as training
recognised through the General Practice Mental Health Standards
Collaboration (GPMHSC).
Annie
Annie is with you for a little over 30 minutes, you itemise
2713.
During the consultation, you suggest it would be best if she
were managed under a GP Mental Health Care Plan to
provide a structured framework for Annie’s care. This also
enables referral pathways to allied mental health providers.
She consents.
You make an appointment for her to return in two days
Annie
Q.
Is Annie eligible for a GP Metal Health Care Plan?
Yes
Eligible patients include:
• Patients in the community
• Private in-patients (including private in-patients who are residents of
aged care facilities) being discharged from hospital, where the GP who
provides the GP Mental Health Care item is providing in-patient care
Annie
Q.
Is it appropriate to do a GP Mental Health Care Plan for
Annie?
Yes
Annie has a mental disorder.
For the purposes of the GP Mental Health Care items, the following are
not regarded as mental disorders:
• Dementia
• Delirium
• Mental retardation
• Tobacco use disorder
Annie
Q. Do you need to be vocationally registered or working in an
accredited practice to do a GP Mental Health Care Plan
(Item 2710)?
No
Annie
You search the Department of Health and Ageing (DoHA)
website before her scheduled appointment and download the
template to assist with a GP Mental Health Care Plan.
Annie
Q. Do you need to use a template for a GP Mental Health
Care Plan?
No
While templates such as the above one from DoHA or
others from Divisions of General Practice are useful tools
and act as a checklist to make sure all aspects of the
descriptor are met (i.e. assessment and preparation). It is
not necessary to use a template as long as you have
adequate and contemporaneous medical records to
reflect that the descriptor has been met.
Annie
As part of her management under the plan you have both
agreed she would benefit from focussed psychological
strategies.
One of the goals you and Annie agree on when formulating
the GP Mental Health Care Plan is for her to receive cognitive
behavioural therapy to improve her low self esteem.
Annie
Q. Who is able to provide CBT for Annie?
• You as the GP*
• A fellow GP to whom you refer Annie*
• Allied Mental Health professionals such as psychologists,
social workers and occupational therapists. As long as they
meet specific eligibility requirements relevant to their
discipline and are registered with Medicare Australia.
*Level 2 mental health training required
Annie
Q. How many CBT visits is Annie eligible for?
The initial referral can be for up to six visits after which the
Allied Mental Health Practitioner should send a report to the
GP and the GP may review the progress (Item 2713) or review
the GPMHCP (Item 2712).
Eligible patients can generally receive up to 12 individual
services in a calendar year in groups of up to six services,
although provision exists for patients to receive additional
services where exceptional circumstances arise.
Annie
Q. Do referring practitioners require a specific form to refer
patients on to eligible allied mental health professionals for
treatment?
No
The referral may be a letter or note to an eligible allied mental health
professional, signed and dated by the referring practitioner. A good
communication strategy is to also include, with the patient’s consent, a
copy of the GPMHCP, to enable the allied health practitioner to see what
goals you are trying to achieve.
Annie
In your area there are no Medicare Registered Mental Health
Allied professionals.
Q. Can you refer her to psychologists employed by Public
Mental Health Services?
Yes
Q. Can you refer her to psychologists employed by your
Division General Practice under the ATAPS (Access to
Allied Psychological Services) funding?
Yes
But - these visits are counted towards the 12 visits in a calendar year that
Annie is eligible for.
Annie
Q. If you as her GP, or another GP, provide focussed
psychological strategies as Level 2 Mental Health Trained
GPs, do these visits (items 2721 - 2727) count towards the
12 eligible visits for Annie?
Yes
Annie
• You do a GP Mental Health Care Plan (Item 2710)
• Provide leaflets on depression, books to read
• Practice nurse provides websites for information, and
emergency and after hours contact numbers
• You refers patient for six CBT sessions to Medicare
registered Psychologist
• Prescribe SSRI after discussion
Annie - three weeks later
Q. You ask Annie to return in three weeks for a review, what
Medicare item number could you charge?
• One appropriate for time, complexity and content of the
consultation
• GP consultation – if predominately mental health issues
discussed + >20 minutes = Item 2713
• If the item descriptor for 2713 is not met, items 23, 36 or 44
may be appropriate
Annie - six weeks later
Annie hasn’t progressed well after six weeks on therapy
Annie breaks down and discloses other complex family
issues
She is not getting on with the registered psychologist
You refer her to a psychiatrist
Annie - six weeks after psychiatrist visit
Sees you for follow up :
• review of the Mental Health Management Plan (item 2712)
• Re-administer the outcome tool and review the goals
• review compliance and suitability of medication
• discuss value of ongoing group therapy sessions
• arrange further referrals to a different clinical psychologist
for one on one sessions as well as group therapy sessions
Annie
Q. How many reviews can you do under a GP Mental Health
Care Plan?
In general, most patients will not require more than two
reviews in a 12 month period.
Q. Could the GP have sent Annie back to the psychiatrist for
the review?
Yes
The consultant psychiatrist would charge Medicare Item 293 to do a review
of a referred patient assessment and management plan.
Questions?
Key points for Mental Health
• Provides GPs a way to obtain the best outcome and more
choices for patients with mental health problems
• Encourages communication and team work with other mental
health providers
• GP remains cornerstone of care for patients with mental
health issues
• No limit or cap on GP Mental Health Care attendance items
(Item 2713)
• Maximum of 12 individual services may be made up of
psychological therapy services, focussed psychological
strategies by appropriately trained GPs and registered Allied
Health practitioners, or a mix of both, including services
provided through ATAPS.
Skin
When to claim consultation with procedure
Appropriate itemisation for common lesion treatment/excisions
Warts and all
Treated a patient with a plantar wart on three occasions in last
three months with cryotherapy and curettage. Patient returns
because the wart is still present.
You repeat the treatment and bill Item 30186 again.
Item 30186 PALMAR OR PLANTAR WARTS (less than 10), definitive
removal of, excluding ablative methods alone,…..
Q. Is this appropriate?
No
This item is for definitive removal, not for treatment of the wart, and should
only be billed once per wart. Other treatment is on attendance basis only
Cryotherapy
Your next patient has a number of solar keratoses, you decide
to treat eight lesions with cryotherapy.
Q.Is billing Item 30202 appropriate for this service?
Item 30202 MALIGNANT NEOPLASM OF SKIN OR MUCOUS
MEMBRANE proven by histopathology or confirmed by specialist
opinion, removal of, BY LIQUID NITROGEN CRYOTHERAPY using
repeat freeze-thaw cycles.
No
The correct item is Item 23
T8.9.2 - Treatment of fewer than 10 solar keratoses by ablative techniques
such as cryotherapy attracts benefits on an attendance basis only.
Skin flaps
You removed a 15mm diameter BCC from your patient’s upper
back. When closing the wound, you undermine the edges of the
wound and decide to bill a local flap repair in addition to the
excision item.
Q. Is this appropriate?
No
• If a wound is closed by flap repair then it is appropriate to bill the lesion
removal and the flap repair (exception is for wedge excision of lip, eyelid
or ear Item 45665, which includes the excision)
• Medicare benefits for flaps are only payable when clinically appropriate.
• T8.93.3 - Undermining of the edges of a wound prior to suturing is
considered a normal part of wound closure and is not considered a skin
flap repair.
Biopsy
Your next patient has a 2.5mm very dark, suspicious looking
lesion - you decide to biopsy the lesion using a 3mm punch.
Q. Is Item 30071 the correct item for the following pathology
results
• 2.5mm dysplastic naevus, margins clear
Yes
• 2.5mm seborrheic keratosis margins clear
No
• 2.5mm pigmented BCC margins clear
Yes
• 2.5mm Clark level 2 malignant melanoma
margins clear
Yes
Item 30071 DIAGNOSTIC BIOPSY OF SKIN OR MUCOUS MEMBRANE,
as an independent procedure, where the biopsy specimen is sent for
pathological examination
Wound repair
Next patient is overweight. On his lateral thigh he has a 5cm
laceration which appears quite deep, but has not included the
fascia
You decide to suture the wound under local anaesthesia.
Q. Is Item 30029 the correct item?
Repair of skin wound, not on face or neck, small (NOT MORE
THAN 7 CM LONG), involving deeper tissue
No—should be Item 30026
The wound needs to involve deeper tissue in order for Item 30029 to be
appropriate. The term 'deeper tissue' means all tissues deep to but not
including subcutaneous tissue such as fascia and muscle.
Consultation and procedure
A patient is booked in for elective removal of a naevus from
the forearm one week after the initial consultation.
The GP removes the lesion. No other service is provided. The
patient is billed an item for the procedure plus an Item 23
(Level B consultation)
Q. Is it appropriate to bill the attendance item with the
procedure in this case?
No
An attendance item must only be billed if a consultation is performed and
the descriptor fulfilled.
Consultation and procedure
The lesion measured 11 x 6 mm in situ. The pathology report
confirmed a dysplastic naevus 11 x 6 mm.
Q. Is Item 31205 the correct item number?
Item 31205 Removal of TUMOUR CYST, ULCER OR SCAR
up to and including 10mm in diameter
Yes
Not Item 31210 > 10mm because average diameter is (6+11)/2 = 8.5mm
Consultation and procedure
BCC
A doctor has previously excised an 8mm lesion on the lower
half of the lower leg. The histopathology report showed a BCC
extending to the margin of excision.
Item 31265 (BCC/SCC removal from … lower leg … up to and
including 10 mm) is billed.
Four weeks later the doctor performs a re-excision however
the histopathology shows only scar tissue.
Item 31266 (BCC/SCC, residual, removal of from face, neck
(anterior to sternomastoid muscles), lower leg (mid calf to
ankle) … up and including 10mm in diameter … same
practitioner…) is billed.
Q. Is this appropriate?
Yes—Item 31266 can be billed
Melanoma
A doctor excised a suspicious lesion on the lateral neck
measuring 8mm. The histopathology shows a melanoma
extending to the margin of excision.
The doctor bills Item 31325 (Malignant melanoma … removal
… tumour size up to and including 10mm in diameter…).
Q. Is this appropriate?
No—Item 31205 should be billed
Item 31205 Removal of TUMOUR CYST, ULCER OR
SCAR up to and including 10mm in diameter
Melanoma re-excision
As the original melanoma excision was incomplete, the doctor
performs a re-excision of the area.
The histopathology confirms the excision is complete.
The doctor bills Item 31325 (Malignant melanoma … removal
… tumour size up to and including 10mm in diameter…).
Q. Is this appropriate?
Yes -melanoma excision Item 31325 should be billed
Lesions on the neck (eg Items 31235 or 31305) need to be
anterior to sternomastoid muscles
Questions?
Key points Skin
• Only bill for clinically relevant items
• Only bill for attendance with a procedure when clinically
relevant
• Document what you do, including measurements of the
lesion prior to removal
• Remember skin cancer items can only be billed once the
pathology result is known and confirms skin cancer
• When uncertain about Medicare itemisation, after checking
the MBS, contact Medicare Australia on 132 150.
Summary
Appropriate use of Medicare is key to quality practice
management and a sustainable health system for all
Australians.
By complying with Medicare you can be proud that you are
providing a quality service and improving health outcomes
Quality practice management is an important aspect of
providing a quality clinical service and quality use of
Medicare
Questions?
Summary
1 Claiming for Services not provided
2.Misitemisation
• selecting the wrong item
• upcoding (claim for a similar item which has a higher
rebate than the service provided eg item 44 for a 20
minute consult)
3. Prescribing outside the criteria for authority and restricted
drugs
In addition it is likely that there will be another audit of CDM
items 721 and 723 in 2009.
The presentation has ended with
the previous slide and the next
few are for the e-handouts only
Mental Health Care Items
• This next few slides can be included in the handout for
information
Mental Health Care Items for General
Practitioners
• Preparation of a GP Mental Health Care Plan (Medicare
Item 2710)
• Review of a GP Mental Health Care Plan (Medicare Item
2712)
• GP Mental Health Care Consultation (Medicare Item 2713)
Medicare Item 2710 - GP Mental Health Care
Plan
Item Description:
Preparation by a medical practitioner (including a general
practitioner, but not including a specialist or consultant
physician) of a GP MENTAL HEALTH CARE PLAN for a
patient (not being a service associated with a service to which
items 2713 or 734 to 779 apply).
Medicare Item 2710
Fee: $153.30 Benefit: 100% = $153.30
Refer to para A.40 of the explanatory notes to this category
Medicare Item 2712 - Review of a GP Mental
Health Care Plan
Item Description:
• Attendance by a medical practitioner
• Review a GP Mental Health Care Plan to which Item 2710
applies
• Review a Psychiatrist Assessment and Management Plan
to which Item 291 applies
Medicare Item 2712
Fee: 102.20 Benefit: 100% = $102.20
Refer to para A.40 of the explanatory notes to this category
Medicare Item 2713 - GP Mental Health Care
Consultations
Item description:
• Professional attendance by a medical practitioner at
consulting rooms
• Taking relevant history, identifying presenting problem(s),
providing treatment, advice and/or referral for other services
or treatments, documenting the outcomes of the consultation
• Time based – lasting at least 20 minutes
• Not being a service associated with a service to which
Medicare items 2710 or 2712 apply).
Medicare Item 2713
Fee: $67.45 Benefit: 100% = $67.45
Refer to para A.40 of the explanatory notes to this category
Medicare Items for Allied Health practitioners
• Clinical Psychologists
Psychological
Therapy Services
• Psychologists
• Social Workers
• Occupational Therapists
Focussed
Psychological
Strategies
Medicare Items for Allied Health practitioners
Under the Better Access initiative Medicare items provide
benefits for the following allied mental health services:
• Psychological therapy (items 80000 to 80020) – provided
by eligible clinical phycologists
• Focussed psychological strategies – allied mental health
(items 80100 to 80170) – provided by eligible psychologists,
occupational therapists and social workers
Refer to M7 of the explanatory notes to this category