Education guide - Billing multiple MBS items
Information for health professionals about complete medical services, billing multiple MBS items and interpreting common MBS phrases.
Make sure you read the relevant Medicare Benefits Schedule (MBS) item descriptions and explanatory notes at MBS Online.
This guide provides scenarios 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 you received.
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 items for the individual services that make up the comprehensive or combined item.
If more than 1 item covers a service, you need to understand each item’s description and requirements so that you can bill the correct item and prevent claiming errors.
Comprehensive item example
The services described in items 49809 and 50112 are an essential part of the service described in comprehensive item 49848.
- Item 49809 - Foot, open tenotomy of, with or without tenoplasty
- Item 50112 - Cicatricial flexion or extension contraction of joint, correction of, involving tissues deeper than skin and subcutaneous tissue, not being a service to which another item in this Group applies
- Item 49848 - Foot, correction of claw or hammer toe.
Cutting the tendon - item 49809 - and correcting the contracted joint - item 50112 - are essential procedures in correcting a claw or hammer toe - item 49848.
This means you only bill comprehensive item 49848 and not individual items 49809 and 50112.
Combined item example
Item 56030 combines both services described in computed tomography (CT) items 56001 and 56022.
- Item 56001 - CT - scan of brain without intravenous contrast medium, not being a service to which item 57001 applies
- Item 56022 - CT - scan of facial bones, para nasal sinuses or both without intravenous contrast medium
- Item 56030 - CT - scan of facial bones, paranasal sinuses or both, with scan of brain, without intravenous contrast medium.
If both services described in 56001 and 56022 are performed on the same occasion, you only bill combined item 56030 and not individual items 56001 and 56022.
Multiple attendances on the same day
You can bill multiple attendances for the same patient on the same day if:
- they are separate attendances with a reasonable lapse of time between them
- the subsequent attendances aren’t a continuation of the other attendances.
Scenario 1 - 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 two 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 2 - Continuation of the initial or earlier attendance
You see a patient and give a prescription for a vaccine. The patient returns to have the injection administered after the pharmacy dispenses it.
You can only bill one attendance item. The second visit was a continuation of the first attendance.
Attendances with other health services
You can bill attendance items in association with another MBS item if:
- the attendance is a 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 1 of the following phrases in its item description:
- 'each attendance'
- 'attendance at which'
- 'including associated consultation'.
These items already include an attendance.
Scenario 3 - Attendance not payable with another service
You see a patient for a consultation before performing peritoneal dialysis.
The description says:
- Item 13112 - Peritoneal dialysis, establishment of, by abdominal puncture and insertion of temporary catheter (including associated consultation).
You can’t bill a consultation item because this service is included in item 13112.
Subsequent attendance with an item in Group T8
You can’t bill subsequent attendance items 105, 116, 119, 386, 2806, 2814, 3010, 3014, 6019, 6052, or 16404 with any Group T8 item with a schedule fee equal to or greater than $309.35, if both services were performed on the same day.
Group T8 items include items 30001-51171.
You can bill specialist subsequent attendance item 111 or consultant physician subsequent attendance items 117, 120, if:
- the procedure is urgent
- you couldn’t predict the procedure before the start of the attendance, and
- the services meet the item descriptions.
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 and 5228|
For more information on CDM, read our education guide - Chronic Disease GP Management Plans and Team Care Arrangements.
There are MBS item descriptions which 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
- 1 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 is not 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 you perform meets this requirement, you should notate ‘separate body area’ or similar either:
- on the account
- in 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 4 - Independent procedure not payable
You perform a knee reconstruction, item 49517, on your patient. On the same occasion you transfer a tendon, item 47966, on the same knee, through a separate incision.
The item descriptions say:
- Item 49517 - Hemiarthroplasty of knee
- Item 47966 - Tendon or ligament, transfer, as an independent procedure.
Because you performed both services on the same body part described in item 49517, you can only bill item 47966. This is true even though you performed the procedures through separate incisions.
Scenario 5 - Independent procedure payable
You see a patient to remove an etonogestrel subcutaneous implant, item 30062, on their left arm. On the same occasion you implant a replacement hormonal implant, item 14206, in the same arm, through another incision.
The item descriptions say:
- Item 30062 - Etonogestrel subcutaneous implant, removal of, as an independent procedure
- Item 14206 - Hormone or living tissue 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 xxxxx applies’
- ‘not in association with item xxxxx’
- ‘other than a service associated with a service to which item xxxxx applies’
- ‘not in conjunction with item xxxx’.
You perform a diagnostic laparoscopy, item 30390, and a laparoscopic appendectomy, item 30572, on the same occasion.
The description for MBS item 30390 states ‘not being a service associated with any other laparoscopic procedure’.
You can only bill one item because item 30572:
- is another laparoscopic procedure
- doesn’t attract a Medicare benefit with any other laparoscopic procedure performed on the same occasion.
You perform a diagnostic laparoscopy, item 30390, and cervical dilatation and uterine curettage, item 35640, under the same anaesthetic.
The description for item 30390 states ‘not being a service associated with any other laparoscopic procedure’.
You can bill both services, as the second service is not a laparoscopic procedure.
You perform a diagnostic laparoscopy, item 30390, at 9 am and a laparoscopic splenectomy, item 31470, at 7 pm on the same day.
The description for MBS item 30390 states ‘not being a service associated with any other laparoscopic procedure’.
Because the services were performed on separate occasions and under different anaesthetics, you can bill both laparoscopic procedures.
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, you should 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.
You treat a patient for an aneurysm of iliac artery by grafting a replacement. You consider billing item 33172 as it describes the service performed. When checking Subgroup 3 under T8 - Surgical Operations, you find item 33124, which describes the service more specifically.
The descriptor for item 33172 states ‘Aneurysm of major artery, replacement by graft, not being a service to which another item in this subgroup applies’.
The descriptor for item 33124 states ‘Aneurysm of iliac artery (common, external or internal), replacement by graft - unilateral’.
You bill item 33124 as it describes the procedure performed. You should only use item 33172 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 - e.g. items 30385, 33845 or 33848 - and bladder catheterisation - item 36800. They should be billed for an independent, stand-alone service and not in association with a surgical procedure.
The multiple operation rule (MOR) applies if you bill two or more MBS items from Category 3, Group T8 for services performed on a patient at the one occasion.
Items in Subgroup 12 of Group T8 are not subject to this rule.
The total schedule fee for all surgical items is calculated 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. The Medicare benefit payable is calculated based on this schedule fee.
Read more about the MOR in explanatory note TN.8.2 at MBS Online.
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Page last updated: 3 August 2020
This information was printed 11 August 2020 from https://www.servicesaustralia.gov.au/organisations/health-professionals/topics/education-guide-billing-multiple-mbs-items/33231. It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.servicesaustralia.gov.au/individuals/site-notices when using this material.