Obstetrics services for Medicare 011-42060040

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FAQs - common enquiries

Table 1: this table contains answers to common enquiries about the assessment of Medicare benefits for obstetric services.

Item	Description
1	What is the difference between planning and management items 16590 and 16591? Item 16590 is for the planning and management of a pregnancy that has progressed beyond 28 weeks, where the medical practitioner is intending to undertake the birth for a privately admitted patient of a private or public hospital. Item 16591 is for the planning and management of a pregnancy that has progressed beyond 28 weeks and the medical practitioner is providing shared antenatal care and is not intending to undertake the birth. For example, the patient will be admitted as a public patient of a public hospital for the birth. Items 16590 and 16591 cannot both be claimed for the same pregnancy.
2	When would item 16500 be used instead of item 16401/16404? Items 16401 and 16404 replace specialist consultation items 104 and 105 and can be billed to Medicare for any specialist obstetric attendance relating to pregnancy. This includes any initial and subsequent attendance with a specialist obstetrician for discussion of pregnancy or pregnancy related conditions or complications, or any postpartum care provided to the patient subsequent to the expiration of normal aftercare period. Items 16500, 91853 and 91858 are not limited to specialists and can be claimed by medical practitioners for routine antenatal attendances.
3	What is the difference between a participating midwife and a practicing midwife working on behalf of a GP (that means the GP bills for this service)? A participating midwife may claim Medicare benefits for services they provide or refer for patients. A practicing midwife may perform services on behalf of, or under the supervision of an eligible medical practitioner. A practicing midwife cannot claim Medicare benefits See Nurses and midwives on the Department of Health and Aged Care website for more details.
4	Are Medicare benefits for obstetric services only payable for females? No. Obstetric items are not restrictive based on a patient's gender. However, a medical practitioner must determine whether their patient has the requisite anatomical feature to perform a particular Medicare service or procedure. It is the responsibility of the treating practitioner to ensure that any service billed to Medicare meets the item descriptor in the MBS and any eligibility requirements in full.
5	What are the expectations for mental health assessments and which items do they apply to? MBS items for the planning and management of pregnancy (16590 and 16591), and for postpartum consultations between 4-8 weeks (16407, 91851 or 91856), now include an expectation that a mental health assessment be offered by the clinician or another suitably qualified health professional. This aims to ensure: early identification of risk factors that may increase a patient's likelihood of experiencing mental health disorders in the perinatal period, as well as the presence of any symptoms of depression or anxiety, and monitoring or referral for appropriate assessment, support and treatment It is intended that drug and alcohol misuse be taken into consideration in the mental health assessment of the patient in order to facilitate education about the inherent risks of drug and alcohol misuse in pregnancy. It is not the intention to require that the mental health assessment include drug and alcohol testing of the patient (e.g. the provision of blood or urine samples).
6	What if a patient does not want to undergo a mental health assessment included in items 16590, 16591, 16407, 91851 and 91856? It is a requirement that a mental health assessment is offered to the patient as part of the service. However, if the patient chooses not to have a mental health assessment they will not be disadvantaged. A record of the patient's decision not to undergo a mental health assessment must be recorded in the medical practitioner's clinical notes.
7	Why has the claimant received a lower Safety Net benefit than what they usually receive for other services? Obstetric items have an Extended Medicare Safety Net (EMSN) Net Cap applied to them. Where the relevant EMSN threshold has been met, the claimant is entitled to the Medicare benefit plus, for out-of-hospital services, whichever is the lower amount of either: EMSN benefit (80% of out-of-pocket costs) EMSN percentage cap (when applicable and may vary between item numbers) EMSN maximum cap (when applicable and may vary between item numbers) See Medicare Safety Net for more details on eligibility, thresholds and calculations.

FAQs - common restrictive situations

Table 2: this table outlines common restrictions relating to obstetric services and the actions for Service Officers.

Item	Description
1	An item restricts with another obstetric item claimed within a 9 month period Do the restrictive items relate to a separate pregnancy? Yes, the restriction can be overridden No, the restrictive item must be rejected Note: If the claim does not have a notation indicating that a separate pregnancy applies, do not contact the patient for confirmation of a second pregnancy. Contact the practice or confirm a separate pregnancy using the patient's history. If a second pregnancy cannot be confirmed, the restrictive item must be rejected.
2	An item returns an age restriction Have the patient's details have been keyed correctly? Yes, override the restriction and continue processing the claim No, amend the details and continue processing the claim
3	Multiple Operation Rule for obstetric services This rule does not apply to MBS items within group T4 - Obstetric services. This rule applies only to surgical operations covered under group T8 - Operations.

Claiming frequencies of antenatal, intrapartum and postnatal services

Table 3: this table outlines claiming frequencies (time dependencies) of obstetric services. Intrapartum means 'in childbirth'.

MBS items	Type of service	Who provides this service	Claiming frequency
16400, 91850, 91855	Antenatal service - *billed by medical practitioner	nurse* midwife* Aboriginal and Torres Strait Islander health practitioner*	10 per pregnancy
16401, 16404	Initial and subsequent specialist obstetric attendances	specialist in obstetrics	One item 16401 per pregnancy per health professional
16406	Antenatal attendance when patient is referred by participating midwife	GP or obstetrician	One per pregnancy
16500, 91853, 91858	Antenatal Attendance	medical practitioner	No limit per pregnancy
16508	Pregnancy complications	medical practitioner	Items 16508 limited to maximum of one visit per day
16509	Pregnancy complications	medical practitioner	No limit per pregnancy
16533, 16534	Pregnancy complications	medical practitioner	3 of each Item 16533 and 16534 per pregnancy
16514	Antenatal cardiotocography	medical practitioner	No limit per pregnancy
16530, 16531	Management of second trimester fetal loss	medical practitioner	No limit per pregnancy
16590, 16591	Planning and management of a pregnancy	medical practitioner	One item 16590 or 16591 per pregnancy
16600 - 16627	Antenatal intervention technique	medical practitioner	Can be claimed for each fetus in a single or multiple pregnancy
51312	Assistance at obstetric procedure	medical practitioner	No limit per pregnancy
82100,	Antenatal Attendance	participating midwife	One item 82100 per pregnancy
82105, 91211, 91218 82110, 91212, 91219	Antenatal Attendance	participating midwife	No limit per pregnancy
82115	Assessment and preparation of a maternity care plan	participating midwife	One per pregnancy. Not same pregnancy as item 16590 or 16591 (unless there are exceptional circumstances)
16515, 16520	Management of birth, care transferred from another medical practitioner	medical practitioner, where they did not provide antenatal care	One birth item per pregnancy
16519	Management of labour and birth	medical practitioner	One birth item per pregnancy
16522	Complex management of labour and birth	medical practitioner	One birth item per pregnancy
16527, 16528	Management of birth, care transferred from a participating midwife	medical practitioner	One birth item per pregnancy
4001, 92136, 92138 792, 92137, 92139 81000, 93026, 93029 81005, 93026, 93029 81010, 93026, 93029	Pregnancy support counselling service	GP non-VR medical practitioner psychologist social worker mental health nurse	Maximum 3 per pregnancy
16407, 91851, 91856	Postnatal professional attendance	obstetrician or GP	Once per pregnancy. Not same pregnancy as item 82140
16408, 91852, 91857	Postpartum attendance	obstetrician, GP or midwife under the supervision of the medical practitioner who attended the birth	One per pregnancy. Not same pregnancy as item 82130, 82135, 82140, 91214, 91215, 91221 or 91222
16564, 16573	Postnatal complications and repairs	medical practitioner	No limit per pregnancy
82130, 91214, 91221, 82135, 91215, 91222	Postnatal attendance	participating midwife	No limit per pregnancy. Not within same pregnancy as item 16408, 91852 or 91857
82140	Postnatal check	participating midwife	One per pregnancy. Not within same pregnancy as item 16408, 91852 or 91857
82116	Management of labour for up to 6 hours, not including birth - out of hospital	participating midwife	One per pregnancy
82118	Management of labour for up to 6 hours, including birth where performed - in hospital	first participating midwife	One per pregnancy. Not within same pregnancy as item 82120, 82123, 82125 or 82127
82120	Management of labour between 6 and 12 hours, including birth where performed - in hospital	first participating midwife	One per pregnancy. Not within same pregnancy as item 82118, 82123, 82125 or 82127
82123	Management of labour for up to 6 hours, including birth where performed - in hospital	second participating midwife	One per pregnancy. Not within same pregnancy as item 82118, 82120, 82125 or 82127
82125	Management of labour between 6 and 12 hours, including birth where performed - in hospital	second participating midwife	One per pregnancy. Not within same pregnancy as item 82118, 82120, 82123 or 82127
82127	Management of labour for up to 6 hours, including birth where performed - in hospital	third participating midwife	One per pregnancy. Not within same pregnancy as item 82118, 82120, 82123, or 82125

Claiming frequencies for obstetrics ultrasound scans

Table 4: this table outlines the claiming frequency of ultrasound scans that are pregnancy-related or for pregnancy complications in the same pregnancy.

MBS items	Ultrasound confirms a multiple pregnancy	Claiming frequency
55706, 55707, 55708, 55709, 55718, 55723*	No	Once per pregnancy *No more than 3 items of NR type ultrasound services in Category 5, Subgroup 5, Group I1 per pregnancy
55700, 55703, 55704, 55705, 55712, 55715, 55721, 55725	No	More than once per pregnancy *No more than 3 items of NR type ultrasound services in Category 5, Subgroup 5, Group I1 per pregnancy
55742, 55743, 55759, 55762, 55768, 55770*	Yes	Once per pregnancy *No more than 3 items of NR type ultrasound services in Category 5, Subgroup 5, Group I1 per pregnancy
55740, 55741, 55764, 55766, 55772, 55774*	Yes	More than once per pregnancy *No more than 3 items of NR type ultrasound services in Category 5, Subgroup 5, Group I1 per pregnancy

Operational Information