General assessing information for Medicare 011-42020000

The Medicare Benefits Schedule (MBS) is made up of both general and category specific information. Explanatory notes relating to the Medicare benefit arrangements and notes that have general application to services are located at the beginning of the MBS. Notes relating to specific items are located at the beginning of each MBS Category.

When searching MBS Online for explanatory notes, it is best to use the Search MBS function and type a specific word or phrase.

The MBS is a publication maintained and updated by the Department of Health, Disability and Ageing (DHDA). Each professional service contained in the MBS has been allocated a unique item number. Located with the item number and description for each service is the schedule fee and Medicare benefit, together with a reference to an explanatory note (if applicable).

Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, State and Territory laws. The day-to-day administration and payment of Medicare benefits is the responsibility of Services Australia.

To view the MBS, see MBS Online on the DHDA website. Inquiries concerning matters of interpretation of MBS items should be directed to Services Australia.

Each medical service listed in the MBS is a complete medical service in itself. However, there are circumstances where a separate benefit is not payable for a particular service when rendered in conjunction with another more comprehensive service or, when rendered under particular circumstances. Such limitations are often identified by the item description.

Only one amount of benefit is payable for each listed medical service whether the service is rendered:

• by the one practitioner
• partly by one practitioner and completed by another practitioner. For example, after care provided other than by the operating practitioner or radiographic examination

When a practitioner renders a comprehensive service listed in an item and components of that service are separately listed under individual items, benefits are payable under the comprehensive item

See also MBS online - general explanatory notes.

Services eligible for Medicare benefits include professional services rendered by:

• registered medical practitioners
• participating optometrists
• approved dental practitioners
• accredited dental practitioners in the treatment of cleft and craniofacial conditions
• eligible nurses, midwives, allied health and dental professionals

All services that are eligible for benefits are listed in either the Medicare Benefits Schedule, or Dental Benefits Schedule.

There are situations where professional services do not attract a Medicare benefit.
This includes:

• telephone consultations (except for some telehealth services)
• issue of repeat prescriptions when the patient is not in attendance
• letters of advice by medical practitioners
• group attendances (unless otherwise specified in the item, for example item 170) such as group counselling, health education, weight reduction or fitness classes
• non-therapeutic cosmetic surgery, see Cosmetic and plastic surgery assessing rules in Medicare
• medical expenses for the service are paid or payable to a recognised (public) hospital
• medical expenses for the services are in relation to a compensable injury or illness for which the patient's insurer or compensation payer has accepted liability, see Split Services
• services rendered to a doctor's dependants, practice partners or partner's dependants
• medical examination which is required for the purposes of:
• life insurance
• superannuation
• provident account schemes
• admission to membership of a friendly society
• mass immunisation
• chelation therapy other than for the treatment of heavy-metal poisoning
• injection of human chorionic gonadotropin (HCG) in the management of obesity
• hyperbaric oxygen therapy in the treatment of multiple sclerosis
• removal of tattoos
• transplantation of a:
• thoracic or abdominal organ, other than a kidney, or a part of an organ of that kind
• kidney in conjunction with the transplantation of a thoracic or other abdominal organ, or part of an organ of that kind
• removal from a cadaver of kidneys for transplantation
• administration of microwave (UHF radio wave) cancer therapy
• cannulation and/or catheterisation of surgical sites associated with pain pumps for post-operative pain management
• filling or re-filling of drug reservoirs of ambulatory pain pumps for post-operative pain management
• euthanasia and any service directly related to the procedure. Services rendered for counselling/assessment about euthanasia will attract benefits.
• post-mortem examinations
• the issue of death certificates, cremation certificates or counselling of relatives, see Services related to deceased person/s

Unless otherwise directed by the Minister, Medicare benefits are not payable for:

• health screening services, see Health screening services
• pre-employment screening services
• medical expenses incurred by the employer or relate to an industrial undertaking of the person to whom the services is rendered
• services that have been rendered by or on behalf of, or under arrangement with the Australian Government, a State or Territory, a local government body or an authorised establishment under the Commonwealth, State or Territory law.

For additional information on services which do not attract Medicare benefits, see MBS Online.

Additional charges or fees

When a service is not clinically relevant, the fee and payment arrangements are a private matter between the practitioner and the patient. This includes:

• consumables that would be reasonably necessary to perform the service, including bandages and dressings
• record keeping fees
• booking fee to be paid before each service
• annual administration or registration fee
• administration costs associated with providing duplicate invoices or transfer of records
• cancellation or missed appointment fees

Medicare benefits are not payable for the issue of a death certificate, although an attendance on a patient at which it is determined that life is extinct can be claimed under the appropriate attendance item. The outcome of the attendance may be that a death certificate is issued, however, Medicare benefits are only payable for the attendance component of the service.

Tests and services performed on cadavers or stillborn babies do not qualify for payment of Medicare benefits. Enquiries of this nature must be handled with sensitivity.

Unless the Minister otherwise directs, Medicare benefits are not payable for health screening services. A health screening service is defined as a medical examination or test that is not reasonably required for the management of a medical condition of the patient.

MBS general explanatory note GN.13.33 outlines the health screening services the Minister has directed Medicare benefits be paid for.

A professional service is a clinically relevant service which is listed in the MBS.

A service is clinically relevant if it is generally accepted in the medical, dental, optometric or allied health profession, as necessary for the appropriate treatment of the patient.

When a service is not clinically relevant, the fee and payment arrangements are a private matter between the practitioner and the patient.

A professional service must be personally performed by the practitioner on not more than one patient on the one occasion to attract Medicare benefits.

The requirement of personal performance is met whether or not essential assistance is provided, according to accepted medical practice.

Professional services which attract Medicare benefits include medical services rendered by or on behalf of a medical practitioner. This includes services where parts of the service are performed by a technician employed by or, in accordance with accepted medical practice, acting under the supervision of the medical practitioner.

The supervising medical practitioner does not need to be present for the entire service, however they must have a direct involvement in at least part of the service.

Supervision requirements will vary between services, generally, supervision requirements are satisfied where the medical practitioner:

• established consistent quality assurance procedures for the data acquisition; and
• personally analysed the data and written the report.

Pathology services can be rendered by a/an:

• Approved Pathology Practitioner (APP)
• medical practitioner on behalf of and under the supervision of an APP
• person, other than a medical practitioner, on behalf of and under the supervision of an APP

Services provided by a practice nurse on behalf of a medical practitioner are provided under the supervision of a general practitioner (GP). The GP retains responsibility for the health, safety and clinical outcomes of the patient. The GP does not have to be present while the practice nurse is providing the service

Benefits are not payable for services when a medical practitioner refers patients to self-employed medical or paramedical personnel, such as radiographers and audiologists who either bill the patient or the practitioner requesting the service.

Situations can arise when benefits payable for services combine elements for which both Medicare and the Department of Veterans' Affairs (DVA), or Medicare and in part by compensation.

Medicare and Veterans' Affairs

Where the:

• medical practitioner determines that a patient may be eligible to benefit under either DVA or Medicare
• patient has two conditions, one of which is coverable by DVA and the practitioner has treated both conditions at the one attendance

The medical practitioner can choose to bill either Medicare or DVA, benefit is not payable from both sources.

A benefit would be payable from both Medicare and DVA where a patient has two distinct and separate attendances with the practitioner for the treatment of separate conditions, one of which is coverable by DVA, see Assessing MBS item restrictions.

Medicare and compensation

Medicare benefits are not payable in respect of a professional service where the medical expenses for the services are in relation to a compensable injury or illness for which the patient's insurer or compensation payer has accepted liability. However, if medical expenses relate to a compensable injury or illness and the insurer or compensation payer is disputing liability, Medicare benefits are payable until liability is accepted.

The practitioner billing for a service is responsible for the accuracy and completeness of the information included on accounts, receipts and assignment of benefit forms even where information has been recorded by an employee of the practitioner.

For details about account and receipt documents, see Account and receipt documents for Medicare claims processing and Bulk bill claims in Medicare.

MSAC advises the Minister on the strength of evidence relating to the safety, effectiveness and cost effectiveness of new and emerging medical services and technologies and under what circumstances public funding, including listing on the MBS, should be supported.

Further information on the MSAC can be found under the MBS general explanatory notes GN.8.22 or on the MSAC website.