GPRA Guide to the Medicare Benefits Scheme

What is the MBS?

MBS is the Medicare Benefits Schedule, a listing of item numbers that you can use as you consult your patients. Some practices are purely bulk-billing which means that you charge these item numbers to your patient and they have no out-of-pocket fees for seeing you. Some practices may be mixed billing which means that they will often bulk bill pensioners and concession card holders and charge a private fee for everyone else. For those being charged a “private fee”, they can claim back the medicare amount.

This document is targeted towards Basic Registrars as you begin to master the MBS. As a basic registrar, I often “undercharged” my patients because I only knew how to use the very basic numbers (items 3, 23, 36, 44). But as you will see, there are many item numbers you can use to remunerate you for the work you are doing. Some of us don’t care about money but please get paid correctly for what services you provide!

You can access the full MBS online at www9.health.gov.au/mbs/search.cfm Please note that this document is only a guide to the MBS. The information is current as of Nov 2007. GPRA does not hold any responsibility for any misuse of the information provided here.

HOW TO USE THIS GUIDE:

There are 3 basic questions you should ask yourself as you work out how much to charge your patient.

Where and When am I seeing my patient? (SECTION 1)

Does your patient fall into any special groups? (SECTION 2)

What procedures have I done on my patient? (SECTION 3)

SECTION 1 – where and when?

AT YOUR CLINIC

3 Obvious problem, characterised by straightforward nature of task that requires

a short patient history and, if required, limited examination and management.

I usually use this for repeat prescriptions, or any attendances lasting < 5 minutes

$15.00

23 Selective history, examination of patient with implementation of a management plan in relation to > 1 problems.

This is your bread and butter item number. I use this for simple multiple problems lasting 5-20 minutes

$32.80

36 Detailed history, an examination of multiple systems, arranging any necessary investigations and implementing a management plan in relation to 1 or more problems, and lasting at least 20 minutes.

I use this for more complex or multiple problems lasting 20-40 minutes

$62.30

44 Exhaustive history, comprehensive examination of multiple systems arranging any necessary investigations and implementing a management plan in relation to > 1 complex problems, and lasting at least 40 minutes.

This is handy for someone who you KNOW is going to take >40 minutes – try to prebook. Sometimes it’s unpredictable and these sort of patients will cause you to run behind in a major way

$91.70

After hours AT YOUR CLINIC

After Hours means a public holiday, after 1 pm on a Saturday, whole day Sunday OR between 8 pm and 8 am on any other day.

These item numbers apply to when you are working in your clinic only.

If your clinic routinely conducts consults during an after hours period, you should use these item numbers and not the items for urgent after hours attendances (1, 2, 601, 602)

5000 (Equivalent of a 3)

$25.65

5020 (Equivalent of a 23)

$43.45

5040 (Equivalent of a 36)

$72.90

5060 (Equivalent of a 44)

$102.35

RESIDENTIAL AGED CARE FACILITY

This is a little complex, as it depends on how many patients you are seeing in your visit per facility. Your computer software should have a calculator to give you the total amount after you key in how many patients you saw.

20 Equivalent of 3 (but seeing the patient in residential care).

35 Equivalent of 23.

43 Equivalent of 36.

51 Equivalent of 44.

HOME VISITS

Charge this if you see patients at a place other than consulting rooms, hospital, residential aged care facility or institution. Cost is determined by how many patients you see in each house. Again, your computer should have an inbuilt calculator to help determine the final cost. You can charge each patient separately as long as they are in a different house.

4 Equivalent of 3

24 Equivalent of 23

37 Equivalent of 36

47 Equivalent of 44

URGENT ATTENDANCE AFTER HOURS

1 Urgent attendance after hours (on not more than 1 patient on occasion). Professional attendance at a place other than consulting rooms (other than attendance between 11 pm and 7 am) in after hours period if:

· Attendance requested by patient or responsible person in, or not more than 2 hours before the start of, the same unbroken after-hours period and

· Patient’s medical condition requires urgent treatment

Urgent attendance is arbitrarily defined as a consult where the medical issue presented must be dealt with immediately – can’t wait till the next day. Useful for those who work after hours covering an emergency department. I generally use this to see the first patient between 8 pm and 11 pm. Please note that if you see more than one patient, you can only claim “1” once. The rest use the 5000, 5020, 5040, 5060, etc.. But certainly you can use this number multiple times in a night if you go home and get called back again

$114.95

2 Equivalent to above but at your consulting rooms.

· It is necessary for the practitioner to return to, and specially open consulting rooms for attendance

$114.95

601 Professional attendance at a place other than consulting rooms, on not more than 1 patient on the 1 occasion – each attendance between 11 pm and 7 am.

· Attendance requested by patient or responsible person in, or not more than 2 hours before the start of, the same unbroken after-hours period and

· Patient’s medical condition requires urgent treatment

Use this for emergency room visits between 11 pm and 7 am. Again, you can only use this once per visit to the facility. Use 5000, 5020, 5040, 5060 if there is more than one patient to be seen there. If you go out of that facility and get called back again, you can use 601 again.

$135.45

602 Equivalent to above but at your consulting rooms.

· It is necessary for the practitioner to return to, and specially open consulting rooms for attendance

$135.45

Bulkbilling incentive items

Check with your practice whether you can use 10990 or 10991.

10990 General medical services

Unreferred medical service for person under 16 years old (ie. 15 years and 364 days old) or is a Commonwealth concession card holder AND is bulkbilled AND is not an admitted patient of a hospital or day-hospital facility.

A nice bonus that can be used in addition to any other item numbers you are billing your patient. E.g. if I did a standard consult + biopsy of a skin lesion I can charge 23 + 10990 + 30071 + 10990.

Can’t claim together with 10991.

$6.35

10991 General Medical services in RRMA 3-7 or Tasmania

As for 10990 but you have to be practicing in RRMA 3-7 or Tassie. You may also use this number in certain suburbs which are classified as “areas of need”. Check with medicare or your practice.

$9.60

SECTION 2 – special groups

45-49 YEAR OLDS

717 45 year old health check

Attendance by a medical practitioner at a place other than a hospital to undertake a health check for a patient between 45 and 49 (inclusive) at risk of developing a chronic disease.

People get confused of how to interpret the eligibility of your patient – it should be anytime from when the patient turns 45 to just before he/she turns 50. What does it mean to “be at risk of developing a chronic disease”? A chronic disease is one that has been or likely to persist for at least 6 months e.g. asthma, cancer, cardiovascular illness, diabetes, mental health conditions, arthritis, musculoskeletal conditions. You need to identify a specific risk factor e.g. lifestyle risk factors (smoking, physical inactivity, poor nutrition, alcohol misuse) biomedical risk factors (high cholesterol, hypertension, impaired glucose metabolism, obesity) or family history of chronic disease.

Often practices would have a proforma available for you to follow in terms of what should be covered in your health check.

You can only claim this ONCE for each eligible patient – this is not an annual health check. If you are not sure if your patient has been billed already, check with Medicare Australia – 132 011)

$102.20

HEALTH ASSESSMENT - OLDER THAN 75 years old.

700 75 year old health check at consulting room

Attendance by a medical practitioner at consulting rooms for a health assessment of a patient who is at least 75 years old.

There is often a proforma you can use on your computer (ask your supervisor). Technically you can only claim this if you have provided the majority of services to the patient over the last 12 months and/or will provide the majority of services in the coming 12 months.

I found it useful to have the practice nurse collect simple info for me before I saw the patient in my room – vitals, BMI, urinalysis, current medications/immunization status, info about continence, ADLs, fall in last 3 months?, social functioning, psychological function, etc… Negotiate with your practice nurse how much or little they can help you with.

You should not claim another item number concurrently (e.g. 23, 36) unless it is clinically indicated that the problem must be treated immediately.

Can’t claim if had 702, 704, 706 claimed within preceding 12 months.

$171.15

702 75 year old health check other than consulting room

Same as 700 except you are conducting your assessment NOT in the consulting room, hospital or aged care facility.

$242.05

ABORIGINAL, TORRES STRAIT ISLANDER

704 55 year old ATSI health check at consulting rooms

Attendance by medical practitioner at consulting rooms for health assessment of a patient who is at least 55 years old of Aboriginal or Torres Strait Islander descender.

Same components as 700 but obviously a different patient population.

$171.45

706 55 year old ATSI health check not at consulting rooms

Attendance by medical practitioner not at consulting rooms, hospital or residential aged care for health assessment of a patient who is at least 55 years old of Aboriginal or Torres Strait Islander descender.

$242.05

708 Child health check

Attendance by medical practitioner at consulting rooms or another place other than a hospital or Residential Aged Care facility, for child health check of patient less than 15 years old inclusive of ATSI descent.

Can’t claim if had 708 within last 9 months.

There are mandatory items that must be ticked off in your history and examination to be able to claim this number.

Most practices will have a proforma you can follow.

$171.15

710 Adult health check

Attendance by medical practitioner at consulting rooms or another place other than a hospital or Residential Aged Care Facility, for an adult health check of ATSI descent between 15 and 55 years old.

Can’t claim if had 710 within last 18 months.

As for 708, there are specific items that must be checked in order for you to claim this number.

$204.00

REFUGEES

714 Refugee/Humanitarian entrant at consulting room

Attendance by medical practitioner at consulting rooms for health assessment for patient who have been granted residency in Australia under the Humanitarian Program.

Again there is often a proforma in your practice that you can follow.

Can not claim if had a 700, 702, 712, 716 already.

Can only claim once for a patient within 12 months of arriving in Australia or receiving residency (whichever is the later).

$204.00

716 Refugee/Humanitarian entrant not at consulting rooms

As for 714 but not at consulting rooms, hospital or residential aged care facility.

$204.00 + $22.95 divided by number of patients seen, up to max 6 patients.

(> 7 patients = $204.00 + $1.70 per patient)

INTELLECTUAL DISABILITY

718 Intellectual disability at consulting room

Attendance by a medical practitioner at consulting rooms for health assessment of a patient with an intellectual disability.

Patient is eligible if he/she has sub-average intellectual functioning (2 SD below average IQ) and would benefit from assistance with daily living activities. If you want to confirm intellectual disability, you can seek verification from paediatrician or from a government provided or funded disability service.

You can claim if you have provided the majority of services to the patient in the last 12 months and/or likely to provide the majority of services in the following 12 months.

Again, there should be a proforma at your practice that you can follow. If not, check with Medicare Australia 132 011 or on their website re: essential components of the health assessment.

If your assessment detects a chronic medical condition and complex care needs, it may be appropriate to involve other health professionals using the PEC Chronic Disease Management items for GP Management Plans and Team Care Arrangements (721-723)

Can’t claim if had 719 in preceding 12 months.

$204.00

719 Intellectual disability not at consulting rooms

As for 718 but not at consulting room, hospital or residential aged care facility

$226.95

CHRONIC OR TERMINAL MEDICAL CONDITIONS

- GP Management Plan

721 Preparation by medical practitioner of a GP Management Plan for a patient.

Some people love this item number, others don’t even use it. It remunerates well for a subpopulation for the things we already do as GPs.

There is often a template that you can follow on your computer – this must include identifying patient needs, management goals, actions to be taken by the patient, treatment and services needed, etc…

You can only use this for patients with a chronic or terminal medical condition – one that has been or is likely to be present for > 6 months. Conditions like asthma, cancer, cardiovascular illness, diabetes, musculoskeletal conditions, stroke, mental illness all qualify. It is important to know what DOES NOT qualify – alcohol or substance abuse, smoking, obesity, unspecified chronic pain, hypertension, hypercholesterolemia, syndrome X, impaired glucose tolerance, pregnancy.

You can only claim this item once every 12 months. If you are unsure if it has been claimed already, you can call Medicare Australia 132 011 to verify the date of a previous plan, if any.

As a rule, you should not claim a standard consultation item number (e.g. 3, 23, 36, 44) with this. BUT if you see the patient for another condition that is not related to the 721 that you can not postpone to another consult, then you can claim another item number. Make sure you say it is “unrelated” when you send to Medicare. Let’s say you planned to do a 721 for a diabetic patient and during the course of the consult, you also treat a severe otitis media. You can claim 23 (unrelated), 721.

Depending on your practice, the practice nurse may assist you in producing the GP Management plan by assessing the patient, identifying patient needs and even making arrangements for services. This can be a big time saver! You must however sit down with the patient to review and confirm all assessments and elements of the service.

$127.70

725 Review of a GP Management Plan

Attendance by a medical practitioner to review a GP management plan.

Use this item number when you are reviewing a 721. You can only claim this once every 3 months, unless there has been a significant change in the patient’s clinical condition. In reality, you should only claim this once every 6 months or so.

$63.85

723 Preparation of Team Care arrangements

Attendance by a medical practitioner to coordinate the development of Team Care Arrangements for a patient.

This item is designed for patients with complex health and care needs, who are seeing or need to see at least 3 health or care providers (including the GP) and who need team based care.

So, basically you need to find 2 other health providers who are needed in the care of this patient. Examples would include Aboriginal health workers, asthma educators, audiologists, dental therapists, dentists, diabetes educators, dietitians, mental health workers, occupational therapists, optometrists, orthoptists, orthotists, prosthetists, pharmacists, physiotherapists, podiatrists, psychologists, registered nurses, social workers, speech pathologists, etc..

You can include another GP if they are providing a service different and distinct from yourself.

Again, a template should exist on your computer and you can ask the practice nurse to help you set up a 723 (just like a 721).

Like the 721, you can only claim this once every 12 months.

Usually you can combine a 721 and 723 but this is not mandatory. However, if you want to use the Enhanced Primary Care Program for referral to an allied health service under medicare, you need both 721 and 723.

Need 721,723 to be able to claim Enhanced Primary Care (EPC) services.

$101.15

727 Coordination of Review of Team Care Arrangements

Attendance by medical practitioner to coordinate a review of Team Care Arrangements coordinated by that medical practitioner.

Same rules apply as 725 but only in relation to a 723.

$63.85

729 Contribute or Review

Contribution by a medical practitioner to a multidisciplinary care plan prepared by another provider OR review of a multidisciplinary care plan prepared by another provider.

$62.30

MENTAL HEALTH

2710 GP Mental Health Care Plan

Preparation by a medical practitioner of a GP Mental Health Care Plan.

Again, there should be a template available at your practice to claim this number.

Use this item number if your patient has a mental disorder that would benefit from a structured approach of their care needs.

Mental disorder is used to describe a range of clinically diagnosable disorders that is significantly affected your patient’s cognitive, emotional or social abilities. It is important to note that this does NOT include dementia, delirium, tobacco use disorder, mental retardation.

You can only claim this once every 12 months, except when there has been a significant change in the patient’s clinical condition or care circumstances.

The Mental Health Care Plan can be used by patients to claim a Medicare rebate when they see a psychologist. Please note that some psychologist will still charge above the Medicare fee… so you must warn patients of an out of pocket fee.

$153.30

2712 GP Mental Health Care Plan review.

Attendance by a medical practitioner to review a GP Mental Health Care Plan prepared by that medical practitioner.

You can only claim this after 1 month of 2710 and once every 3 months of a 2712, except when there has been a significant change in the patient’s clinical condition or care needs that require a new Mental Health Care Plan.

$102.20

2713 Attendance relating to a mental disorder and consultation lasting >20 minutes.

$67.45

SECTION 3 - PROCEDURES

11506 Spirometry before and after bronchodilator.

$18.50

11700 12 lead ECG, tracing and report.

$28.20

11610 Measurement of Ankle:Brachial Indices and arterial waveform analysis.

$57.55

12000 Skin sensitivity testing for allergens (1-20 allergens).

$35.15

12003 Skin sensitivity testing for allergens (>20 allergens)

$53.15

73805 Microscopy of urine (stained or not) or catalase test

$4.60

73806 Pregnancy test

$10.20

73810 Microscopy for fungi in skin, hair or nails.

$6.95

73811 Mantoux test

$11.30

13706 Administration of blood or bone marrow already collected

$75.30

14206 Hormone or living tissue implantation by cannula (includes Implanon)

$32.15

30062 Removal of etonogestral subcutaneous implant (Implanon)

$54.85

41500 Removal of foreign body (other than ventilating tube) from ear other than by simple syringing

$74.50

14203 Hormone or living tissue implantation, by direct implantation involving incision and suture.

$46.20

35503 Introduction of intrauterine contraceptive device.

$48.35

30207 Multiple injections with hydrocortisone or similar preparations for skin lesions

$40.25

50124 Aspiration or injection into joint or other synovial cavity. Payable on not more than 25 occasions in any 12 month period.

$26.75

51306 Assistance at a delivery involving Caesarean section

$112.60

TREATMENT OF DISLOCATIONS BY CLOSED REDUCTION

47018 Elbow

$178.45

47036 Interphalangeal joint

$76.55

47000 Mandible

$63.85

47042 Metacarpophalangeal joint

$101.95

47057 Patella

$114.70

47024 Radioulnar joint, distal or proximal

$178.45

47015 Shoulder (not GA)

$76.55

47069 Toe

$63.85

FRACTURE

47354 Carpal Scaphoid

$153.10

47348 Carpus (excluding scaphoid)

$84.90

47462 Clavicle

$101.95

47576 Fibula

$101.95

47444 Shaft of Humerus

$204.10

47336 Metacarpal

$153.10

47339 Metacarpal (Intra-articular)

$178.45

47633 Metatarsal (treatment of 1)

$101.95

47642 Metatarsal (treatment of 2)

$136.15

47579 Patella

$144.55

47300 Distal Phalanx of finger or thumb (incl percutaneous fixation)

$76.55

47312 Middle Phalanx of finger

$114.70

47324 Proximal Phalanx of finger or thumb

$153.10

47663 Phalanx of great toe

$127.55

47360 Radius or Ulna (distal end) by cast immobilisation

$119.05

47378 Radius or Ulna (shaft) by cast immobilisation

$153.10

47369 Radius distal end (Colles’, Smith’s, Barton’s)

$153.10

47471 Ribs (1 or more) – each attendance

$38.80

47561 Tibia (shaft) by cast immobilisation

$246.50

47546 Tibia (plateau, medial or lateral #)

$306.05

SKIN PROCEDURES

REMOVAL OR BIOPSY

30071 Diagnostic biopsy of skin or mucous membrane, as an independent procedure where the biopsy specimen is sent for pathological examination.

$47.15

30067 Removal of foreign body in muscle, tendon or other deep tissue

$201.95

30192 Ablation of > 10 premalignant skin lesions (incl solar keratoses)

$35.75

30064 Removal of subcutaneous foreign body requiring incision and exploration incl closure of wound

$99.25

30061 Removal of superficial foreign body (incl from cornea or sclera)

$21.20

30202 Removal by liquid nitrogen cryotherapy of malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion

$43.65

WOUND REPAIR

Basic questions to ask is whether it is < 7 cm or > 7cm, superficial or deep, and whether it is on the face or neck. This will determine your item number.

30026 < 7 cm, superficial (not face or neck)

$47.15

30029 < 7 cm, deep (not face or neck)

$81.25

30032 < 7 cm, superficial

$74.50

30035 < 7 cm, deep

$106.15

30038 >7 cm, superficial (not face or neck)

$81.25

30041 >7cm, deep (not face or neck)

$130.05

30045 >7cm, superficial

$106.15

30048 >7cm, deep

$135.20

30052 Full thickness laceration of ear/eyelid/nose or lip

$229.35

BASIC SKIN LESION REMOVAL

The usual practice is to take out the skin lesion and send to pathology without charging the patient. Then once histology arrives, you can determine how much you will charge depending on the underlying pathology.

BCC or SCC or Keratoacanthoma

Removal from nose, eyelids, lip, ear, digit, genitalia

31255 < 10 mm

$199.90

31260 > 10 mm

$285.10

Removal from face, neck (anterior to sternomastoid) or lower leg (mid calf to ankle)

31265 < 10 mm

$166.60

31270 10-20 mm

$233.25

31275 >20mm

$270.25

Removal from areas of body not covered by above

31280 < 10 mm

$140.75

31285 10-20 mm

$192.35

31290 >20 mm

$222.05

Malignant Melanoma, appendageal carcinoma, malignant fibrous tumor of skin, Merkel cell carcinoma of skin or Hutchinson’s melanotic freckle

Removal from nose, eyelid, lip, ear, digit of genitalia

31300 < 10 mm

$288.90

31305 >10 mm

$355.40

Removal from face, neck (anterior to sternomastoid muscles) or lower leg (mid calf to ankle)

31310 < 10 mm

$251.65

31315 10-20 mm

$318.35

31320 >20 mm

$355.40

Removal from areas of body not covered by above

31325 < 10 mm

$244.35

31330 10-20 mm

$288.90

31335 >20 mm

$333.20

BURNS

30006 Dressing of extensive burns

$42.00

30003 Dressing of localised burns

$32.80

OTHER

30219 Incision and drainage of haematoma, furuncle, small abscess or similar lesion.

$24.70

30216 aspiration of haematoma

$24.70

30195 Treatment of benign neoplasm of skin (other than common warts), seborrheic keratoses, cysts, skin tags by electrosurgical destruction, simple curettage, shave excision, laser photocoagulation.

$57.35

30106 Excision of ganglion or small bursa.

$140.30

30186 Definitive removal of palmar or plantar warts (<10) excluding ablative methods alone.

$42.85

30099 Excision of sinus (superficial)

$81.25

30213 Diathermy or sclerosant injection of telangiectasia or starburst vessels on Head or Neck (lesions visible from 4 m). Maximum of 6 sessions in 12 months.

$99.15

IF THERE IS A PRACTICE NURSE IN YOUR ROOMS

10993 Immunisation provided to a person by a practice nurse if

· Immunisation is provided on behalf of, and under the supervision of, a medical practitioner and

· Person is not an admitted patient of a hospital or approved day hospital facility

(See how your practice nurse functions in your specific practice. In some practices, if your patient comes for a standard consult (23) then asks for an immunisation on top of this, you can get the practice nurse to do it and so you can charge 10993 on top of your 23)

$10.85

10996 Treatment of a person’s wound (other than normal aftercare) provided by a practice nurse if

· Treatment is provided on behalf of, and under supervision of, a medical practitioner and

· Person is not an admitted patient of a hospital or day hospital facility

(Same as above, if nurse is happy to do dressings for you, you can charge 10996 on top of your consult fee)

$10.85

10994 Services provided by a practice nurse, being the taking of a cervical smear and preventive checks if

· Service is provided on behalf of, and under supervision of, a medical practitioner and

· Person is not an admitted patient of a hospital or day hospital facility

$21.70

10995 Services provided by a practice nurse, being the taking of a cervical smear from a woman between 20 and 69 inclusive, who has not had a cervical smear in the last 4 years and preventive checks if

· Service is provided on behalf of, and under supervision of, a medical practitioner and

· Person is not an admitted patient of a hospital or day hospital facility

$21.70

10998 Service provided by practice nurse, being the taking of a cervical smear from a person if

· Service is provided on behalf of, and under supervision of, a medical practitioner and

· Person is not an admitted patient of a hospital or day hospital facility

(Just for pap smear… without preventive check)

$10.85

10999 Same as 10995 except no preventive check.

$10.85

10997 Service on behalf of medical practitioner for patient with a GP management plan or team care arrangement which is consistent with the care plan (max 5 services per patient per calendar year)

(You can only access this if the patient has a GP Management Plan, Team Care Arrangements or Multidisciplinary Care plan) You can use this for patients who require access to ongoing care, routine treatment and ongoing monitoring and support between the more structured reviews of the care plan by yourself. Use this for checks on clinical progress, monitoring medication compliance, self management advice, collection of info to support GP reviews of Care Plans)

$10.85