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You can find out more about the relevant Medicare Benefits Schedule (MBS) item descriptions, factsheets and explanatory notes at MBS Online.
We’ve provided scenarios in this guide for example purposes only. When you bill an item, it’s your responsibility to:
- understand the complete medical service principle
- select the correct item for the service you provide
- meet the conditions of the description of the item
- consider whether your peers would choose the same treatment for your patient.
If you bill an item incorrectly, you may get a penalty and need to repay the money.
For help with interpreting the MBS contact AskMBS.
Complete medical service
Each professional service listed in the MBS is a complete medical service in itself.
A complete medical service covers all components required to perform the service described.
There are also items that describe comprehensive or combined services. This means the item includes other individual services, which are essential to that complete medical service.
If you bill a comprehensive or combined item, you can’t also bill the individual services that make up these items.
If more than one item covers a service, you need to understand each item’s description and requirements. This will help you bill the correct item and prevent claiming errors.
Scenario 1 - Comprehensive item
Item descriptions relevant to your procedure:
- MBS item A - open tenotomy of foot, with or without tenoplasty
- MBS item B - correction of contracted joint, involving tissues deeper than skin and subcutaneous tissue
- MBS item C - foot, correction of claw or hammer toe.
Cutting the tendon (item A) and correcting the contracted joint (item B) are essential procedures in correcting a claw or hammer toe (item C).
This means you only bill comprehensive service MBS item C if performed on the same toe. You can’t bill the other individual procedure items.
Scenario 2 - Combined item
Your patient is referred for 2 computed tomography (CT) services. The item descriptions say:
- MBS item D - scan of brain without intravenous contrast medium
- MBS item E - scan of facial bones, without intravenous contrast medium
- MBS item F - scan of facial bones with scan of brain, without intravenous contrast medium.
Both scan of the brain (item D) and scan of the facial bones (item E) are described in a combined service (item F).
This means you can only bill combined service MBS item F when they’re performed on the same occasion. You can’t bill the individual imaging items.
Multiple attendances on the same day
You can bill multiple attendances for the same patient on the same day if:
- they’re separate attendances with a reasonable lapse of time between them
- the subsequent attendances aren’t a continuation of the other attendances.
Scenario 3 - Separate attendances
You see a patient to treat a sore throat in the morning. The same patient returns at 4 pm the same day seeking treatment for a sprained ankle.
You can bill the appropriate attendance item for each attendance. The second attendance was not a continuation of the earlier consultation. There was a reasonable lapse of time between the 2 visits.
Make note of the time of each attendance on the account or include service text for electronic claims. This will help us assess the claim.
Scenario 4 - Continuation of the initial or earlier attendance
You see a patient for a preliminary eye examination with the instillation of mydriatic. The patient returns after 30 minutes and you undertake an eye refraction.
You can only bill one attendance item. The second visit was a continuation of the first attendance.
Scenario 5 - Co-claiming a COVID-19 vaccine suitability assessment service with another attendance
Encourage patients presenting with multiple clinical matters to book a separate consultation.
If urgent clinical treatment is required and another attendance is unrelated to the vaccine assessment item, you can bill both items. You must meet requirements of both services.
Make a note on the account or include service text for electronic claims. Suitable text may include:
- times of each attendance
- ‘Unrelated to COVID-19 assessment’ on the attendance item.
This will help us assess the claim.
To find out more go to the fact sheet.
Attendances with other health services
You can bill attendance items in association with another MBS item if:
- the attendance is clinically relevant
- you meet the item description of all items.
There are certain restrictions that prevent billing attendance items in association with other MBS items.
You can’t count the time spent performing non-attendance items when selecting the appropriate attendance item to bill.
Attendance not payable with another service
You can’t bill an attendance item with an item containing one of the following phrases in the item description:
- ‘each attendance’
- ‘attendance at which’
- ‘including associated consultation’.
These items already include an attendance.
Scenario 6 - Attendance not payable with another service
You see a patient for a consultation before performing electroconvulsive therapy.
The description says, ‘MBS item G - Electroconvulsive therapy, with or without the use of stimulus dosing techniques, including any electroencephalographic monitoring and associated consultation’.
You can’t bill a consultation item because this service is included in the item description.
Subsequent attendance with an item in Group T8
There are some subsequent attendance items which can’t be billed on the same day with any Group T8 surgical item either:
- equal to the applicable threshold
- greater than the applicable threshold.
These are attendance items 105, 116, 119, 386, 2806, 2814, 3010, 3014, 6009, 6011, 6013, 6015, 6019, 6052, or 16404.
Group T8 items include items 30001-51171.
You can bill specialist subsequent attendance item 111, 117 or 120, if each of the following apply:
- the procedure is urgent
- you couldn’t predict the procedure before the start of the attendance
- the service meets the item description.
You can bill subsequent attendance item 115 if each of the following apply:
- the attendance is urgent
- you couldn’t predict the attendance prior to the procedure
- the attendance is unrelated to the scheduled T8 surgical procedure
- the service meets the item description and requirements.
Find out more about this co-claiming limitation in MBS Note AN.3.1.
Attendance items provided on the same day as a Chronic Disease Management (CDM) service
You can’t bill CDM items and certain attendance items for the same patient on the same day. If you bill a CDM and restricted attendance item, we’ll only pay a benefit for the CDM item.
|This restriction prevents co-claiming CDM items:||with attendance items:|
|229, 230, 233, 721, 723 and 732||3, 4, 23, 24, 36, 37, 44, 47, 52, 53, 54, 57, 58, 59, 60, 65, 179, 181, 185, 187, 189, 191, 203, 206, 585, 588, 591, 594, 599, 600, 733, 737, 741, 745, 761, 763, 766, 769, 5000, 5003, 5020, 5023, 5040, 5043, 5060, 5063, 5200, 5203, 5207, 5208, 5220, 5223, 5227, 5228|
Find out more about CDM, go to Chronic Disease GP Management Plans and Team Care Arrangements.
Magnetic Resonance Imaging (MRI) scans
Consultations in conjunction with MRI scans
You can’t claim a consultation in conjunction with MRI scans at the same attendance.
The following consultation items restrict with MRI scan items:
Your consultation is payable if you determine it’s necessary for the treatment of your patient’s condition.
You’ll need to provide supporting text with your claim indicating the need for the consultation.
Scenario 7 - Consultation and MRI scan at same attendance
You perform an MRI scan. You can consider item 52, 53, 54, 57, 104 or 105 at the same attendance if the following apply:
- you need to consult with your patient to alter, or potentially alter, the course of your patient’s management and treatment
- you take primary responsibility for the management decisions made during the consultation
- the consultation includes components of history taking, physical examination, discussion with the patient, formulation of management plans and referral for additional opinions or tests.
You must have a referral to bill specialist referred consultation items 104 or 105 that’s different from the request for the MRI.
Co-claiming head and spine MRI scans
Only one MRI scan for the same region is payable at the same attendance. If the patient has more than one scan, the MBS item with the highest fee will attract a benefit.
You’ll get paid for more than one item where both of these apply:
- the requester states there is a clinical need for separate and distinct scans
- you indicate this on your claim.
You’ll need to provide supporting text with your claim if the services are performed:
- at separate attendances
- were clinically needed.
|Restrictions apply to MBS items in Category 5|
|Head MRIs - Group I5, Subgroup 1 to 5||Items in range 63001 to 63131 restrict with each other|
|Spine MRIs - Group I5, Subgroup 6 to 10||Items in range 63151 to 63280 restrict with each other|
To find out more about MRI Co-claiming rules, go to Changes to MBS items and rules for diagnostic imaging services fact sheet.
There are MBS item descriptions that include the phrase ‘as an independent procedure’. Medicare benefits are not payable for both an item containing this phrase and another procedure where either:
- you perform the procedure through the same incision as another procedure
- the procedure occurs in the same body area as another procedure
- one procedure is an integral part of another procedure.
How to tell if these limitations apply to the independent procedure item you’ve performed
If the independent procedure isn’t an integral part of another procedure you’ve performed, check the description of all the items you performed on the same occasion. This will help you determine if you can bill the independent procedure.
If any of the items mention a body area or part, you can only bill the independent procedure if you performed the service on a different body area. If the independent procedure meets this requirement, notate ‘separate body area’ or similar in either the:
- claim text.
If the items don’t mention a body area or part, you can bill the independent procedure if you performed it through a separate incision. Make sure you note ‘separate incision’ or similar on the account or claim text.
Scenario 8 - Independent procedure not payable
You perform a knee reconstruction on your patient. On the same occasion you excise a cyst on the same knee, through a separate incision.
The item descriptions say:
- MBS item H - arthroplasty of knee
- MBS item I - excision of cyst, by open or arthroscopic means, performed as an independent procedure.
Because you performed both services on the same body part described in arthroplasty item H, you can only bill that item. This is true even though you performed the procedures through separate incisions.
Scenario 9 - Independent procedure payable
You see a patient to remove a subcutaneous foreign body from their left arm. On the same occasion, you insert a hormonal implant in the same arm, through another incision.
The item descriptions say:
- MBS item J - removal of subcutaneous foreign body, requiring incision and exploration, including closure of wound if performed, as an independent procedure
- MBS item K - hormone implantation by cannula.
Because the items don’t specify a body area and you’ve used separate incisions, you can bill both items.
To help us assess the claim, include a note on the account or text indicating ‘separate incisions’ or similar.
Not being a service associated with
Some MBS item descriptions prevent us paying Medicare benefits when the service is performed in association, on the same occasion, with either:
- a specific MBS item number or item range
- another MBS item within the same group
- another MBS item within the same subgroup
- a similar type of service or procedure.
For example, some item descriptions include ‘not being a service associated with a service to which another item in this group applies’. This means that we can’t pay Medicare benefits when you perform another item from the same group on the same occasion.
Some item descriptions include ‘not being a service associated with a service to which another item in this subgroup applies’. This means we can’t pay Medicare benefits when you perform any other item in the same subgroup on the same occasion.
Other common phrases found in MBS item descriptions with similar definitions include:
- ‘not being a service associated with a service to which item xxx applies’
- ‘not in association with item xxx’
- ‘other than a service associated with a service to which item xxx applies’
- ‘not in conjunction with item xxx’.
Scenario 10 - Not being a service associated with
You perform 2 laparoscopy services on the same occasion.
The item descriptions say:
- MBS item L - laparoscopy, diagnostic, not being a service associated with any other laparoscopic procedure
- MBS item M - laparoscopy appendectomy.
You can only bill item M because:
- it’s another laparoscopic procedure
- item L doesn’t attract a Medicare benefit with any other laparoscopic procedure performed on the same occasion.
Scenario 11- Not being a service associated with
You perform 2 procedures under the same anaesthetic.
The item descriptions say:
- MBS item N - laparoscopy, diagnostic, not being a service associated with any other laparoscopic procedure
- MBS item O - cervical dilatation and uterine curettage.
You can bill both services, as the second service is not a laparoscopic procedure.
Scenario 12 - Not being a service associated with
You perform a diagnostic laparoscopy at 9 am and a laparoscopic splenectomy at 7 pm on the same day.
The description for the item performed at 9 am states ‘not being a service associated with any other laparoscopic procedure’.
You can bill both laparoscopic procedures because the services were performed:
- on separate occasions
- under different anaesthetics.
Not being a service to which another item in this group or subgroup applies
You can only bill an item with one of the phrases below if there isn’t a more specific item for the service:
- ‘not being a service to which another item in this group applies’
- ‘not being a service to which another item in this subgroup applies’
- ‘other than a service to which another item in the table applies’
- ‘other than a service to which any other item applies’.
These phrases often apply to items that describe a service in generic terms. If another item exists that describes the service more specifically, use that item.
You should only use generically described items if:
- the service is clinically relevant
- the service meets the item description, and no other MBS item describes the service.
You can bill other MBS items for additional services performed on the same occasion.
Scenario 13 - Not being a service to which another item in this group or subgroup applies
You treat a patient for an aneurysm of iliac artery by grafting a replacement. You consider billing an MBS item as it describes the service performed. When checking Subgroup 3 under T8 - Surgical Operations, you find another item which describes the service more specifically.
The item description says:
- MBS item P - replacement by graft for aneurysm of major artery, not being a service to which another item in this subgroup applies
- MBS item Q - unilateral replacement by graft for aneurysm of iliac artery.
You can bill MBS item Q as it describes the procedure performed. You should only use the less specific first item when no other item within Subgroup 3 describes the procedure.
Where no other procedure is performed
You can bill an item containing the phrase ‘where no other procedure is performed’ when both:
- the procedure is performed in isolation on the patient
- no other procedure occurs at the time.
Items with this phrase are usually procedures for controlling post-operative bleeding and bladder catheterisation. You should bill these items for an independent, stand-alone service and not in association with a surgical procedure.
Multiple operation rule
The multiple operation rule (MOR) applies if you bill 2 or more MBS items from Category 3, Group T8 for surgical services performed on a patient on one occasion.
Amputation items in Subgroup 12 of Group T8 are not subject to this rule.
You can calculate the total schedule fee for all surgical items by applying the MOR. That is:
- 100% of the fee for the item with the highest schedule fee
- plus 50% of the fee for the item with the next highest schedule fee
- plus 25% of the fee for any further surgical items.
Applying this rule results in one total schedule fee for all surgical items billed. We calculate the Medicare benefit payable based on this schedule fee.
Find more about the MOR in MBS note TN.8.2.