General assessing information for Medicare 011-42020000

The Medicare Benefits Schedule (MBS) is made up of both general and category specific information. General information is located at the beginning of the MBS and is referred to as the General Explanatory notes. General explanatory notes include information such as:

• provider and public eligibility for the Medicare scheme
• billing procedures and services which do not attract a Medicare benefit

Category specific information is found at the beginning of each MBS category.

Note: there are additional Medicare Benefits Schedules for Dental Services and Optometrical Services.

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

The Medicare Benefits Schedule (MBS) is a publication that is maintained and updated by the Department of Health and Aged Care (DoHAC). Each professional services 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 relating to the item (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 benefits under the Medicare arrangements is the responsibility of Services Australia. To view the MBS, see MBS Online on the DoHAC website. Inquiries concerning matters of interpretation of MBS items should be directed to Services Australia.

Each medical service listed in the Schedule 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 easily identified by the item description.

Only 1 amount of benefit is payable for each listed medical service whether the service is rendered:

• by the 1 practitioner
• partly by 1 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 which are eligible for Medicare benefits include professional services rendered by:

• registered medical practitioners
• optometrical consultations by participating optometrists
• prescribed dental services by approved dental practitioners
• prescribed dental services by accredited dental practitioners in the treatment of cleft lip and cleft palate conditions
• eligible services provided by Nurses, Midwives, Allied Health and Dental Professionals

All services that are eligible for benefits are listed in 1 of the following:

• Medicare Benefits Schedule
• Schedule of Medicare Benefits Optometrical Services Schedule
• Medicare Benefits Schedule Dental Services

There are situations where professional services rendered by approved providers do not attract a Medicare benefit. Below are some circumstances where services do not attract a Medicare benefit. For additional information on services which do not attract Medicare benefits, see MBS Online.

• Telephone consultations
• Issue of repeat prescriptions when the patient does not attend the surgery in person
• 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
• Where the medical expenses for the service are paid or payable to a recognised (public) hospital
• 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
• Medical examination which is required for the purposes of:
• Life insurance
• Superannuation
• Provident account schemes
• Admission to membership of a friendly society
• Mass immunisation
• Health screening services
• Pre-employment screening services
• Professional services which are employment related and the expenses are incurred by the employer or relate to an industrial undertaking (unless otherwise directed by the Minister)
• Services that have been rendered by or on behalf of, or under arrangement with the Commonwealth, State or local governing body or authority similarly established
• Chelation therapy (that is, the intravenous administration of ethylene diamine tetra-acetic acid or any of its salts) other than for the treatment of heavy-metal poisoning
• The injection of Human Chorionic Gonadotropin (HCG) in the management of obesity
• Hyperbaric oxygen therapy in the treatment of multiple sclerosis
• The removal of tattoos
• The transplantation of a thoracic or abdominal organ, other than a kidney, or a part of an organ of that kind
• Transplantation of a kidney in conjunction with the transplantation of a thoracic or other abdominal organ, or part of an organ of that kind
• The administration of microwave (UHF radio wave) cancer therapy, including the intravenous injection of drugs used in the therapy
• For services rendered to a doctor's dependants, practice partners or partner's dependants

Additional charges or fees

• 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

The services listed below do not attract Medicare benefits:

• post mortem examinations
• euthanasia and any service directly related to the procedure. However, services rendered for counselling/assessment about euthanasia will attract benefits
• the removal from a cadaver of kidneys for transplantation purposes
• attending a deceased person for the issue of a death or cremation certificate or where a doctor attends a deceased person to certify that life is extinct for the purposes of removing a body

Although Medicare benefits are not payable for the issue of a death certificate, a Medicare benefit is payable where a health professional:

• attends a patient who dies in their presence, with or without resuscitation attempts
• attends a person who may or may not be dead and they have to either verify death or institute treatment if the person is alive. The following interpretation applies to this situation - legally, only a medical practitioner can verify that life is extinct and, until a statement of death or death certificate is issued, the patient is still regarded as an eligible patient for Medicare benefit purposes. Situations may arise where the medical practitioner is aware, prior to the attendance, that the patient is still not alive (for example, through nursing staff). Such an attendance to verify death would attract a Medicare benefit even if the practitioner subsequently issues a death certificate or statement of death. Only the time taken to examine the patient and verify death attracts benefit. Other non-clinical tasks, for example, issuing a death certificate are not eligible for benefits and should not be considered in determining the appropriate attendance item

Medicare benefits are payable for professional services which are considered clinically relevant services for the appropriate management of a patient’s condition. Services carried out on cadavers or stillborn babies do not come within the definition of a professional service. Services or tests, for example, medical research, forensic evidence or other legal requirements (issue of death certificate) do not attract a Medicare benefit. Enquiries of this nature need to be handled with sensitivity.

Unless the Minister otherwise directs, Medicare benefits are not payable for health screening services. The Health Insurance Act 1973 defines a health screening service as a medical examination or test which is not reasonably required for the management of a medical condition of the patient.

The Medicare Benefits Schedule (MBS) General Explanatory notes advise health screening services which the Minister has directed Medicare benefits be paid for, see MBS online - general explanatory notes - services which do not attract Medicare benefits.

A professional service is defined as a clinically relevant, service rendered by a medical or dental practitioner, an optometrist or an eligible allied health professional.

A clinically relevant services is defined as a service that is generally accepted in the medical, dental, optometric or allied health profession, as being necessary for the appropriate treatment of the patient to whom it is rendered.

With the exception of services advised in the Medicare Benefits Schedule (MBS) General Explanatory notes, services must be personally performed by the practitioner on not more than 1 patient on the 1 occasion to attract Medicare benefits.

The requirement of physical performance is met whether or not assistance is rendered in the performance of the service according to accepted medical standards.

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

In defining the term supervision in accordance with accepted medical practice, the supervision requirements are deemed to be satisfied where the medical practitioner has both:

• established consistent quality assurance procedures for the data acquisition
• personally analysed the data and written the report
• pathology services can be rendered by:
• an Approved Pathology Practitioner (APP)
• a medical practitioner on behalf of and under the supervision of an APP
• a 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) and the GP retains responsibility for the health, safety and clinical outcomes of the patient. This does not mean that the GP has to be present while the practice nurse is providing the service

Benefits are not payable for these services when a medical practitioner refers patients to self-employed 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

Situations can arise when benefits payable for services combine elements for which both Medicare and the DVA are responsible.

Where the:

• medical practitioner determines that a patient may be eligible to benefit under either DVA or Medicare
• patient has 2 conditions, 1 of which is coverable by DVA and the practitioner has treated both conditions at the 1 attendance

The medical practitioner can choose to bill either organisation but cannot claim half the fee from either source, that is, benefit is not payable from both sources.

A benefit would be payable from each source where a patient has 2 distinct and separate attendances with the practitioner for the treatment of separate conditions, 1 of which is coverable by DVA, see Assessing MBS item restrictions.

Medicare and compensation

Situations can arise where services rendered to a patient is covered in part by Medicare and in part by 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.

In order for Medicare benefits to be paid, a properly itemised account or receipt must be issued.

Section 19(6) of the Health Insurance Act 1973 and Regulation 13 of the Health Insurance Regulations 2018 require the following particulars to be shown on the account or receipt or direct billing form:

• the patient's name
• the date the service was rendered
• the amount charged in respect of the service
• the total amount paid in respect of the service
• any amount outstanding in respect of the service
• a description of service sufficient to identify the item that relates to the service and, when rendered to a patient classified as an admitted patient, the words admitted patient preceding the service description or an * immediately after the item number where used
• the name and practice address or name and provider number of the provider who actually rendered the service
• the name and practice address or name and provider number of the practitioner receiving or claiming payment of (assignment of) benefits:
• for services in Group A1-A14, D1, T1, T4-T9, Groups O1-O7 and Group P9 - where the person claiming benefit is not the person who rendered the service
• for services in Groups D2, T2, T3, I2 to I5 - every service
• where the practitioner receiving or claiming benefits is not the practitioner who provided the service, that is, locum situations, the words 'PAY P' must be included together with the name and practice address or the name and provider number of the practitioner claiming the benefit
• if the service was a specified simple basic pathology test that was determined necessary by a practitioner who is another member of the same group medical practice, the surname and initials of that other practitioner
• if a practitioner has rendered more than 1 professional attendance to the same patient on the same day and a Category 1 item relates to each attendance - the time at which each attendance commenced
• where the service rendered relates to a consultant or specialist in the practice of their specialty and the patient has been referred:
• the name and either practice address or provider number of the referring practitioner
• the date of the referral
• the period of the referral (where other than for 12 months), that is, 3, 6, 18 months or indefinitely. Referrals for longer than 12 months should only be used where the patient’s clinical condition requires continuing care and management of a specialist or a consultant physician for a specific condition or conditions
• additional information is required for diagnostic imaging and pathology accounts, see 5 Diagnostic imaging assessing rules in Medicare and Understanding Pathology assessing rules in Medicare

Note: if information recorded on accounts or receipts or assignment forms is done by an employee of the practitioner, the practitioner claiming for the service bears responsibility for the accuracy and completeness of the information.

The MCRP was created to oversee the assessment of applications for Medicare Benefits Schedule (MBS) items that required approval prior to payment of a Medicare benefit.

The MCRP was an expert panel of medical advisors from the Department of Health and Aged Care DoHAC who assessed clinical evidence submitted by the servicing provider, to determine if the clinical requirements were met for the 26 designated MCRP MBS items.

Health professionals are no longer required to seek prior approval to claim MCRP items for services performed after 1 November 2018.

Practitioners must still apply to the MCRP for services performed before 1 November 2018.

The Medicare Services Advisory Committee (MSAC) was established in April 1998 and advise the Minister for Health 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 Medicare Benefits Schedule (MBS), should be supported.

Further information on the MSAC can be found under the General Explanatory Notes of the MBS or alternatively on the MSAC website.