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Make sure you read the relevant Medicare Benefits Schedule (MBS) item descriptions and explanatory notes at MBS Online.
Complex neurodevelopmental disorder and eligible disability
MBS items are available for diagnosing and treating patients with an eligible disability.
The initiative links Better Start for Children to the Helping Children with Autism program (HCWA). These programs are now part of the NDIS. Patients with both an eligible disability, or complex neurodevelopmental disorder (such as autism spectrum disorder) can access MBS services associated with these programs. When creating a treatment and management plan you should consider both conditions.
Age criteria for MBS services
The patient must be under 25 years of age to have:
- allied health MBS items for assistance in diagnosing the patient or contributing to a treatment plan
- a treatment and management plan prepared by a specialist, consultant physician or general practitioner.
The patient must be under 25 years of age to have allied health MBS items for treatment services.
Eligible disabilities include:
- sight loss resulting in vision of less than or equal to 6/18 vision or equivalent field loss in the better eye, with correction
- hearing loss with either
- a hearing loss of 40 decibels or greater in the better ear, across 4 frequencies
- permanent conductive hearing loss and auditory neuropathy
- cerebral palsy
- Down syndrome
- Fragile X syndrome
- Prader-Willi syndrome
- Williams syndrome
- Angelman syndrome
- Kabuki syndrome
- Smith-Magenis syndrome
- CHARGE syndrome
- Cri du Chat syndrome
- Cornelia de Lange syndrome
- Microcephaly, if a child has
- a head circumference less than the third percentile for age and sex
- a functional level at or below 2 standard deviations below the mean for age on a standard development test or an IQ score of less than 70 on a standardised test of intelligence
- Rett’s disorder
- Fetal Alcohol Spectrum Disorder (FASD)
- Lesch-Nyhan Syndrome
- 22q deletion syndrome.
When diagnosing children with microcephaly:
- a standard developmental test refers to either
- a Bayley Scales of Infant Development
- the Griffiths Mental Development Scales standard development test
- a standardised test of intelligence refers to
- the Wechsler Intelligence Scale for Children
- the Wechsler Preschool and Primary Scale of Intelligence.
It is the diagnosing practitioner’s clinical judgement whether other tests are appropriate.
Billing and referral requirements
To be eligible for Medicare benefits:
- you, as the medical practitioner or allied health professional, must provide all services to the eligible patient personally
- you must provide the service to a single patient on a single occasion
- the patient must be present for all services provided. Where appropriate, specialist or consultant physicians can use telehealth video consultations.
Allied health services don’t attract Medicare benefits until we’ve paid the prerequisite medical practitioner item.
Allied health professionals must provide allied health assessment and treatment items as non-admitted or outpatient services.
There’s no specific referral form for allied health services. A signed and dated referral letter or note that includes the required number of services is acceptable.
Patients need a separate referral for each allied health professional they’re referred to. They also need a separate referral for assessment and diagnosis services and treatment services.
Referrals for allied health treatment services can include up to 10 services per course of treatment.
You must retain referrals and management plan documents for 2 years.
Overview of the initiative
The item numbers for the initiative are designed to be used in 3 stages:
- Assessment and diagnosis.
- Making a treatment and management plan.
- Treatment services.
At the end of each stage, the responsible health professional should provide a written document. This could be a referral, a treatment plan or a report.
The table below shows the stages and the documents you need to provide at each stage.
|Stage||Health professional||MBS items, referrals and reporting|
|Assessment and diagnosis||Medical practitioners||
To assess and diagnose patients:
If you need help from an allied health professional to diagnose the patient you must write a referral for up to 4 services.
Up to 8 allied health assessment services are payable per eligible child’s patient’s lifetime.
|Allied health professionals||
To assess and diagnose patients:
Each assessment service must be a minimum of 50 minutes.
The allied health professional must submit a report to the referring practitioner after the assessment.
|Treatment and management plan||Medical practitioners||
To complete a treatment and management plan:
Only one treatment and management plan item is payable per eligible patient’s lifetime.
If the treatment and management plan allocates allied health treatment services you must write a referral. A maximum of 10 services can be allocated in each course of treatment.
Up to 20 allied health treatment services are payable per eligible patient’s lifetime.
|Treatment services||Allied health professionals||
To provide treatment services:
Each treatment service must be a minimum of 30 minutes.
The allied health professional must submit a report to the referring practitioner after each course of treatment.
Further information for medical practitioners
Treatment and management plan
Plans under MBS item 137 and 92141 or 139 and 92142 must include:
- an assessment and diagnosis of a patient’s condition
- a risk assessment covering
- risk of contributing co-morbidity
- environmental, physical, social and emotional risk factors that may apply to the patient or to another individual
- treatment options and decisions
- recommendations for medicine if required.
If you’ve allocated treatment services to allied health professionals, you must give them a copy of the completed treatment and management plan along with the referral. If you’re a specialist or consultant physician, you should also give a copy of the treatment and management plan to the initial referring provider.
Review and follow up
You should use the following MBS items or telehealth equivalents to review the plan or provide additional referrals:
- items 104-109 if you’re a specialist
- items 110, 116, 119, 122, 128, 131 or 296-308, 310, 312, 314, 316, 318, 319-352, if you’re a consultant physician
- items 3-47 if you’re a general practitioner.
Further information for allied health practitioners
A maximum limit of 4 allied health services per day applies for the eligible patient.
Reports to the referring medical practitioner should include:
- assessments carried out
- treatment provided
- recommendations on future management for the patient’s disability
- advice given to third parties, for example, parents and schools.
Read more about:
- the Better Start for Children with Disability initiative
- the Helping Children with Autism program
- the schedule at MBS Online
- education services for health professionals
- our website disclaimer.
Contact us for Medicare provider enquiries.
Provide your feedback on our education resources.