Medicare items for Complex Neurodevelopmental Disorders and eligible disabilities

Information about services available in the Medicare Benefits Schedule (MBS) for Complex Neurodevelopmental Disorders and eligible disabilities, previously part of the Helping Children with Autism program and the Better Start for Children with Disability initiative.

Make sure you read the relevant Medicare Benefits Schedule (MBS) item descriptors and explanatory notes at MBS Online.

Complex Neurodevelopmental Disorders and eligible disabilities

MBS items are available for assessing, diagnosing and treating patients with a Complex Neurodevelopmental Disorder, such as Autism Spectrum Disorder or an eligible disability.

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
  • allied health MBS items for treatment services.

Complex Neurodevelopmental Disorders

A Complex Neurodevelopmental Disorder covers patients who’ll require support across multiple domains.

Diagnosing a Complex Neurodevelopmental Disorder requires:

  • evidence that support is needed
  • impairment across 2 or more neurodevelopmental domains with complex multi-domain cognitive and functional disabilities.

It’s up to the diagnosing practitioner’s clinical judgement whether their patient meets the definition of a complex neurodevelopmental disorder. Read more about Medicare Benefits Schedule Note AN.0.24 and Note AN.0.72 on the Department of Health and Aged Care website.

Eligible disabilities

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
  • deafblindness
  • 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’s a matter for 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 clinically appropriate, medical practitioners and allied health professionals 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.

Referrals

There is 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 plans for 2 years.

Overview of the referral pathways

The item numbers for assessment, diagnosis and treatment cover:

  • 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 refer to allied health assessment MBS services for a Complex Neurodevelopmental Disorder:

To refer to allied health assessment MBS services for an eligible disability:

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 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 for an eligible disability:

  • specialists and consultant physicians can use item 137 or 92141
  • general practitioners can use item 139 or 92142.

To complete a treatment and management plan for a Complex Neurodevelopmental Disorder:

  • consultant paediatricians can use item 135 or 92140
  • consultant psychiatrists can use item 289 or 92434.

Only one treatment and management plan item is payable per eligible patient’s lifetime.

You must write a referral if the treatment and management plan allocates allied health treatment services. 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 135, 137, 139 and 289 and telehealth 92140, 92141, 92142 or 92434 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:

Further information for allied health practitioners

A maximum limit of 4 allied health services per day applies for the eligible patient.

Written reports

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.

More information

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Page last updated: 12 September 2023.
QC 33771