Medicare Billing Summary

8/4/2019 Medicare Billing Summary

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Practice Incentive Payments and Service Incentive Payments Summary

ITEM ACTIVITYITEM NUMBER &TYPEOF

CONSULT

PIP

($ PER

WPE)

SIP

($ PER PATIENT)NOTES

Diabetes

Patient register andrecall / remindersystem

N/A

$1.00(Approx.$1,000 per FTEGP)

One-off payment onlyPractice must be registered for PIPIncentive payable with quarterly PIP payments

Annual cycle of carefor patients withDiabetes

In-surgery consultations:Level B - 2517 ($32.10)Level C 2521 ($60.95)Level D 2525 ($89.75)

$40per patient

These item numbers should be used in place of the usual attendance items, when aconsultation completes the minimum annual requirements of care. Payable once peryear per patient.

Outcomes payment N/A $20.00Payment made ONLY to practices where 20% of diabetes have completed an Annual

Cycle of CarePayment only made to practices that have a min. of 2% of all patients with diabetes

Asthma

Asthma Cycle of Care

In-surgery consultations:Level B 2546 ($32.10)Level C 2552 ($60.95)Level D 2558 ($89.75)

$100 per patientAsthma initiative is for patients with moderate to severe asthma.At least 2 asthma related consultations within 12 months (review consultation is to be a

planned consultation)

These item numbers will trigger the payment of an incentive through the Practice Incentives Program (PIP) in addition to attracting a Medicare rebate.

Cervical

Screening

Sign-on payment N/A$0.25(Approx. $250per FTE GP)

One-off payment onlyPractice must be registered for PIPIncentive payable with quarterly PIP payments

Screening at riskwomen who have notbeen screened in thepast 4 years

In-surgery consultations:Level B 2501 ($32.10)Level C 2504 ($60.95)Level D 2507 ($89.75)

$35 per patient

Payments are made for women screened between the ages of 20-69 yrs.These MBS items must be used instead of the standard consultation items, in order tobe eligible for this paymentThese MBS items can not be used in conjunction with items 10994, 10995, 10998 or

10999 (as these are practice nurse item numbers for cervical screening)

Outcomes payment N/A$3 per patient

Screened(WPE)

Payment is made to practices where a min. of 70% of women aged between 20 and 69yrs have been screened in the past 12 months

Accredited practices registered with the SIP will receive the extra incentive of $35 when claiming item 10995 & 10999Nurse must be qualified and trained to take cervical smears and conduct preventative checks


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ITEM ACTIVITYITEM NUMBER &TYPE

OFCONSULT

PIP

($ PER

SWPE)

SIP

($ PERPATIENT)NOTES

Immunisation

Completing an Age-appropriateimmunisationschedule

N/A $18.50 per patient

Monies paid to GPs who notify the Australian Childhood Immunisation Register (ACIR)of a vaccination that completes an age-appropriate immunisation scheduleA Notification Payment from the ACIR is also given. SIP is paid monthly.GPs must complete a registration form - ACIR Payment Account Details ForImmunisation Providers which is lodged with Medicare AustraliaEnquiries: 1800 653 809

ACIR notification $6.00

Outcomes payment N/A

$3.50 (per

WPE)

$3.50 for age-appropriate immunisation rate 90% and overPractices must register with the General Practice Immunisation Incentive (GPII)

Program. Enquiries: 1800 246 101 orwww.medicareaustralia.gov.au

Mental

Health

3-Step Process1. Assessment2. Mental HealthPlan3. Review of MentalHealth Plan

Level C / D 36 / 44Item:In surgery 2574 / 2577Out of surgery 2575 / 2578

N/A

SIP of $150 PlusConsultation fees Min.$290 - $360 per patient,p.a

NB: This does not includeadditional consults andEPC Care Plan revenues.

Assessment must be specific and documented.Plans include medications, adverse effects, family involvement, crisis plan, etc.NB: The Mental Health Plan does NOT have to be a multi-disciplinary, although an EPCCare Plan is an option.Reviews will require a recall consultation to review progress and make amendments, ifnecessary. These must be done between 4 weeks and 6 months after the original plan.

NB: 3 Step Mental Health Program able to be claimed untilAPRIL 2007
http://www.medicareaustralia.gov.au/http://www.medicareaustralia.gov.au/


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ITEM ACTIVITY PIP NOTES

IM/IT

Tier 1:The practice maintains electronic patient records, which include clinical data onallergies/sensitivities for the majority of active patients; andThe practice implements appropriate information security measures (eg: virusprotection, firewall, backup& recovery, access control and practiceprocedures/processes to support/maintain appropriate information security). Thepractice also uses appropriate security (e.g. encryption )

$4.00(per SWPE)

A Security Self Assessment (SSA) tool has been developed forthis purpose. The SSA is based on the materials developed bythe GPCG.

Practices must meet all the requirements in the SSA that apply totheir practice IT category.

Practices may wish to use and IM/IT specialist to assist with theSSA

A copy of the SSA can be found at www.gpcg.org.auor contactyour division on 43 65 2294

Tier 2:The practice qualifies for Tier 1 and

The practice uses electronic patient records to record and store clinicalinformation n the majority of active patient records, including current and pastmajor diagnoses and current medications.

$3.00(per SWPE)

Payments for the IM/IT incentive will be paid quarterly

The practice must inform Medicare of any changes thatmay affect the practices eligibility for the PIP/SIPincentive

Practices that qualify to Tier 2, have already met the requirements for Tier 1. Therefore the total payment received by practices will be: $3 + $4 = $7 per SWPE

ITEM ACTIVITY PIP NOTES

AfterHoursCare

Tier 1:Ensuring patients have access to 24-hour care as specified in the applicationform.

$2.00(per SWPE)

After Hours refers to any time outside 8am to 6pm weekdays and 8amto 12noon on Saturday

Tier 2:Practices > 2000 SWPEOn average, the practice covers at least 15 hours per week of its after hourscare from within the practicePractices < 2000 SWPEOn average, the practice covers at least 10 hours per week of its after hourscare from within the practice

$2.00(per SWPE)

This arrangement must be for all its patientsThis is in addition to Tier 1 payment

Tier 3:The practice provides 24-hour care from within the practice

$2.00(per SWPE)

All after hours care must be provided to all patients from within thepractice.This is in addition to Tier 1&2 payments

Quality

Prescribing

Practice participation in quality use of medicines programs, endorsed by TheNational Prescribing Service

$1.00(per SWPE)

This incentive is to assist practices in keeping up to date withinformation on the quality use of medicines.Payment will only be made if the practice meets a minimumparticipation level, set at three activities per FTE GP per year

Teaching

Teaching of medical students $100 per session

Payments are made to practices that host university medical studentplacements.Maximum2 sessions per day(As perwww.medicareaustralia.gov.ay/providers/incentives/allowances/pip)Enquiries: CCDGP 4365 2294 or Medicare Australia PIP Helpline: 1800 222 032 or www.medicareaustralia.gov.au
http://www.gpcg.org.au/http://www.gpcg.org.au/http://www.medicareaustralia.gov.ay/providers/incentives/allowances/piphttp://www.medicareaustralia.gov.ay/providers/incentives/allowances/piphttp://www.medicareaustralia.gov.au/http://www.medicareaustralia.gov.ay/providers/incentives/allowances/piphttp://www.medicareaustralia.gov.ay/providers/incentives/allowances/piphttp://www.medicareaustralia.gov.au/http://www.gpcg.org.au/http://www.medicareaustralia.gov.ay/providers/incentives/allowances/piphttp://www.medicareaustralia.gov.au/


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GP ManagementPlan

Patient with chronic conditionthat has been, or is likely to be

present, for at least six months or

that is terminal. (Not necessarilyrequiring multidisciplinary care).

GPMP Set up

Item 721Claimed by GP withassistance of PN or other

Every 2 years

Contact patient by phone or send a letter

Arrange a time to see the patientThis can be carried out in a number of ways by a number of people:

Opportunistically- when patients make an appointment with the practice, flag them as eligible fora GPMP

Register and recall system

The Pencs Clinical Audit Tool to generate a list of eligible patients, excluding in-active patientsetc.

General Practitioner

Practice NurseReception/ Administration staff

Practice Manager

Prepare a written plan using the practice template and keep in patient file.This can be prepared:

Prior to, or during the consult with the patient, book a long consult with the GP

By the practice nurse, Allied Health Professional (AHP) or an Aboriginal Health Worker (AHW)with or with out the patient present.

If preparation is done by practice nurse, AHP or an AHW it must be followed by a 10-15 minuteconsult with the patients normal GP to finalise and sign the plan.

Include:Individualised goal setting, information and advice for the patient

List and record information and resources handed to or discussed with patientThe person providing the service and their contact detailsLifestyle goals / changes to achieve such as smoking status, nutrition, alcohol intake andphysical activity level as well as addressing the guidelines for management of the chroniccondition(s) the patient is diagnosed with.

Claim Item Number 721. The GP can claim the item number once all documentation is complete,patient consent obtained and the GP has seen the patient.

Check for eligibility and existing care plan- ask patient/ check with Medicare Australia

Discuss benefits of and cost involved in the care planAssess patient

Identify, agree to and record patient needs and relevant conditions, goals to be achieved, actionsplanned, and the person providing the treatment/ service

Patient signature or a record of their consent on plan and print a copy for patientAdd a copy to the patients file and if a copy is required by any other health providers, patientconsent for information sharing must be recordedDiscuss options for Team Care Arrangement Plan (if clinically required)Schedule date for review of plan in 3-6 months time

If the patient has:Diabetes- complete and Annual Cycle of Care SIP and consider group referral (see over).Asthma- consider the Asthma Annual Cycle of Care SIP

A mental health issue- consider GP Mental Health Care PlanA mental health issue and complex health care needs- they are also eligible for the GPMental Health Care Plan: Item number 2710 or 2702 as well as 723 and 721

Identify

Prepare

Consult

After

GP Management PlanFlow Chart Item 721

GPMP Review

Item 732Claimed by GP withassistance of PN orother

Every 3-6 months, orwhen clinically required


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Examples ofChronic Diseases

AIDS/ HIVArthritis-

osteoarthritis,osteoporosis,rheumatoidarthritis

AsthmaChronic KidneyDiseaseCOPDChronic RenalImpairment

Colorectal CancerCoronary HeartDiseaseDementiaDiabetesLung CancerMental HealthMost cancers

(excluding BCC,SCC of skin)

Multiple SclerosisOral DiseasesPalliative careParkinsonsDiseaseProstate CancerStrokeThyroid illness

Exclusion ListObesity, Smoking, Unspecified chronic pain, Pregnancy, Impaired glucose tolerance,

Hypercholesterolaemia, Hypertension and Syndrome X.On their own these are not regarded as chronic conditions. A patient may have complications or co-morbidities that maybe a result of or exacerbated by such risk factors making them eligible for CDM services.

721 and 723 Guidelines

A GPMP and a TCA can both be claimed at the same time provided the twoservices are delivered as per the Medicare items.The TCA does not need to be an entirely separate document to the GPMPpreventing unnecessary duplication. Provided the relevant information isdocumented. The TCA can be included as an addition to the patient's GPMP

as an extra page that includes the goals, the collaborating providers, thetreatment/services they have agreed to provide, patient actions and a reviewdate.A separate standard consultation should not be billed with a GPMP, TCA orreview of either service unless it is clinically indicated that a problem must betreated immediately; or the GPMP was not the original purpose of theconsultation. Accounts that include both a CDM item and a consultation mustbe annotated accordingly.

elbourne East GP Network acknowledges Adelaide North East Division of General Practice for the development of thisflowchart

ResourcesFor resources, referral forms and templates visitwww.megpn.com.au.

721 Referral Options

As of May 1 2007, the allied health items 81100 to 81125 allows people withtype 2 diabetes with a GPMP to receive Medicare rebates for group servicesprovided by eligible diabetes educators, exercise physiologists and dietitians,on referral from a GP. These services are in addition to the five individual alliedhealth services available to eligible patients each calendar year under items10950 to 10970.For more information visit the Department of Health and Ageing website at:www.health.gov.au/epc

723 Referral OptionsPatients with both a GPMP and TCA in place are eligible for 5 Allied Healthrebated services and per calendar year. Allied Health Professionals who utilisethese rebated visits include: Aboriginal Health Worker, Audiologist,

Chiropractor, Diabetes Educator, Dietitian, Exercise Physiologist, MentalHealth Worker, Occupational Therapist, Osteopath, Physiotherapist, Podiatrist,Psychologist, and Speech Pathologist.In a TCA referrals can be made to other professionals that are not involved inMedicare rebates these can include: Asthma Educator, Social worker, Quitline,Arthritis SA, Weight management, Home Medicines Review, RDNS, HelpingHand, Meals On Wheels, Pharmacists (preferably for medication managementthrough a Home Medicines Review- Item 900), and the Practice Nurse (as longas they are providing a service independent to the role of the GP.)
http://www.megpn.com.au/http://www.megpn.com.au/http://www.megpn.com.au/http://www.health.gov.au/epchttp://www.health.gov.au/epchttp://www.megpn.com.au/


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Team CareArrangement

Claim with or with out a GPManagement Plan

Claimed by GP with assistanceFor patients requiringmultidisciplinary care

TCA Preparation

Item 723Claimed by GP with

assistance of PN or otherEvery 6 months

TCA Review

Item 732Claimed by GP with

assistance of PN or otherEvery 3-6 months, orwhen clinically required

A Team Care Arrangement allows patients with chronic conditions needing multidisciplinarycare access to Allied Health Professionals accompanied with Medicare Rebates for thesevisits (5 visits per calendar year per patient). Identifying eligible patients can be carried out ina number of ways:

During the preparation of the GP Management Plan discuss whether the patient could benefitfrom the care provided by another health professional(s) and decide what profession(s) would bemost beneficial.

Prior to consult; in a previous consult it may have been discussed what Health Professionalswould be required.

After a number of months with a GPMP in place the patient might require outside healthprofessional in put into the management of their chronic disease, a TCA can be prepared at thispoint in time.

Communicate with the identified Allied Health Professionals (AHP) via phone conversation,email, letter or fax regarding the individual needs of the patient goals and outcomes desired.

Discuss reporting/ communication methods between the AHP and the GP in relation to patientprogress.Confirm the bulk billing or gap arrangements that suit the patients needs.

Note: to be eligible to receive the 5 allied health rebated visits the patient MUST have both a 721AND 723 claimed and recorded with Medicare Australia. If the claim is made via mail this can takeup to 2 weeks to process by Medicare; delaying the closest possible AHP visit to 2 weeks after theclaim of a 723.

A separate document for a TCA is not necessary if there is an existing GPMP. Document theAHP or other health professional involved in the TCA, their name, contact details, agreement toparticipate, and the goals for their treatment and services for the patient.

Claim Item Number 723. The GP can claim the item number once all documentation is complete,patient consent obtained, agreement from AHP to participate and the GP has seen the patient.

Discuss AHP goals with the patient either prior to confirmation with AHP (claim a normal consultor if appropriate an item 721- preparation of a GP Management Plan) or following confirmationwith AHP (in this case an item 723 can be claimed on the day of the consult with the patient).

Note: Prior to claiming item 723 participation from all AHP must be confirmed

Practice Nurse can be utilised to discuss option for care with patient, and investigate AHP andother health professionals and gain agreement to participate.Fill in the EPC Referral Form- indicating the number of visits allocated the AHP filling inseparate forms for each AHP involved. Give form(s) to patient for AHP to claim for the rebatefrom Medicare.Patient signature or a record of their consent on plan and print a copy for patientAdd a copy to the patients file and if a copy is required by any other health providers, patientconsent for information sharing must be recordedSchedule date for review of plan in 3-6 months time

If the patient has:

Diabetes- complete and Annual Cycle of Care SIP if required.

Identify

Prepare

Consult

After

Team Care ArrangementFlow Chart Item 723


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elbourne East GP Network acknowledges Adelaide North East Division of General Practice for the development of this

Exclusion List

Obesity, smoking, unspecified chronic pain, pregnancy, impaired glucose tolerance,

hypercholesterolaemia, hypertension and Syndrome X.On their own these are not regarded as chronic conditions. A patient may have complications or co-morbidities that maybe a result of or exacerbated by such risk factors making them eligible for CDM services.

721 and 723 Guidelines

A GPMP and a TCA can both be claimed at the same time provided the twoservices are delivered as per the Medicare items.The TCA does not need to be an entirely separate document to the GPMPpreventing unnecessary duplication. Provided the relevant information is

documented. The TCA can be included as an addition to the patient's GPMP asan extra page that includes the goals, the collaborating providers, thetreatment/services they have agreed to provide, patient actions and a reviewdate.A separate standard consultation should not be billed with a GPMP, TCA orreview of either service unless it is clinically indicated that a problem must betreated immediately; or the GPMP was not the original purpose of theconsultation. Accounts that include both a CDM item and a consultation must beannotated accordingly.

ResourcesFor resources, referral forms and templates visitwww.megpn.com.au.

721 Referral Options

As of May 1 2007, the allied health items 81100 to 81125 allows people withtype 2 diabetes with a GPMP to receive Medicare rebates for group servicesprovided by eligible diabetes educators, exercise physiologists and dietitians,on referral from a GP. These services are in addition to the five individual alliedhealth services available to eligible patients each calendar year under items10950 to 10970.For more information visit the Department of Health and Ageing website at:www.health.gov.au/epc

723 Referral OptionsPatients with both a GPMP and TCA in place are eligible for 5 Allied Healthrebated services per calendar year. Allied Health Professionals who utilise

these rebated visits include: Aboriginal Health Worker, Audiologist,Chiropractor, Diabetes Educator, Dietitian, Exercise Physiologist, MentalHealth Worker, Occupational Therapist, Osteopath, Physiotherapist, Podiatrist,Psychologist, and Speech Pathologist.In a TCA referrals can be made to other professionals that are not involved inMedicare rebates these can include: Asthma Educator, Social worker, Quitline,Arthritis SA, Weight management, Home Medicines Review, RDNS, HelpingHand, Meals On Wheels, Pharmacists (preferably for medication managementthrough a Home Medicines Review- Item 900), and the Practice Nurse (as longas they are providing a service independent to the role of the GP.)

Examples ofChronic Diseases

AIDS/ HIVArthritis-

osteoarthritis,osteoporosis,rheumatoidarthritis

AsthmaChronic KidneyDiseaseCOPDChronic RenalImpairment

Colorectal CancerCoronary HeartDiseaseDementiaDiabetesLung CancerMental HealthMost cancers

(excluding BCC,SCC of skin)

Multiple SclerosisOral DiseasesPalliative careParkinsonsDiseaseProstate CancerStrokeThyroid illness
http://www.megpn.com.au/http://www.megpn.com.au/http://www.megpn.com.au/http://www.health.gov.au/epchttp://www.health.gov.au/epchttp://www.megpn.com.au/

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