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Category 1 - PROFESSIONAL ATTENDANCES
291 - Additional Information
Professional attendance by a consultant physician in the practice of his or her speciality of PSYCHIATRY where the patient is referred for the provision of an assessment and management plan by a medical practitioner practising in general practice (including a general practitioner, but not including a specialist or consultant physician) or participating nurse practitioner, where the attendance is initiated by the referring practitioner and where the consultant psychiatrist provides the referring practitioner with an assessment and management plan to be undertaken by that practitioner for the patient, where clinically appropriate.
An attendance of more than 45 minutes duration at consulting rooms during which:
- An outcome tool is used where clinically appropriate
- A mental state examination is conducted
- A psychiatric diagnosis is made
- The consultant psychiatrist decides that the patient can be appropriately managed by the referring practitioner without the need for ongoing treatment by the psychiatrist
- A 12 month management plan, appropriate to the diagnosis, is provided to the referring practitioner which must:
a) comprehensively evaluate biological, psychological and social issues;
b) address diagnostic psychiatric issues;
c) make management recommendations addressing biological, psychological and social issues; and
d) be provided to the referring practitioner within two weeks of completing the assessment of the patient.
- The diagnosis and management plan is explained and provided, unless clinically inappropriate, to the patient and/or the carer (with the patient's agreement)
- The diagnosis and management plan is communicated in writing to the referring practitioner
Not being an attendance on a patient in respect of whom, in the preceding 12 months, payment has been made under this item
Fee: $452.65 Benefit: 85% = $384.80
(See para A19 of explanatory notes to this Category)
Category 1 - PROFESSIONAL ATTENDANCES
Consultant Psychiatrist - Initial consultations for NEW PATIENTS (Items 296 to 299 and 361) Referred Patient Assessment and Management Plan (Items 291, 293 and 359) and referral to Allied Mental Health Professionals
Referral for items 291, 293 and 359 should be through the general practitioner or participating nurse practitioner for the management of patients with mental illness. In the event that a specialist of another discipline wishes to refer a patient for this item the referral should take place through the GP or participating nurse practitioner.
In order to facilitate ongoing patient focussed management, an outcome tool will be utilised during the assessment and review stage of treatment, where clinically appropriate. The choice of outcome tools to be used is at the clinical discretion of the practitioner, however the following outcome tools are recommended:
- Kessler Psychological Distress Scale (K10)
- Short Form Health Survey (SF12)
- Health of the Nation Outcome Scales (HoNOS)
Preparation of the management plan should be in consultation with the patient. If appropriate, a written copy of the management plan should be provided to the patient. A written copy of the management plan should be provided to the general practitioner within a maximum of two weeks of the assessment. It should be noted that two weeks is the outer limit and in more serious cases more prompt provision of the plan and verbal communication with the GP or participating nurse practitioner may be appropriate. A guide to the content of the report which should be provided to the GP or participating nurse practitioner under this item is included within this Schedule.
It is expected that item 291 will be a single attendance. However, there may be particular circumstances where a patient has been referred by a GP or participating nurse practitioner for an assessment and management plan, but it is not possible for the consultant psychiatrist to determine in the initial consultation whether the patient is suitable for management under such a plan. In these cases, where clinically appropriate, items 296, 297, 299 or 361 (for a new patient) or 300-308 (for continuing patients) may be used, and item 291 may be used subsequently, in those circumstances where the consultant psychiatrist undertakes a consultation (in accordance with the item requirements) prior to the consultation for providing the referring practitioner with an assessment and management plan. It is not intended that items 296, 297, 299, 361 or 300-308 will generally or routinely be used in conjunction with, or prior to, item 291.
Items 293 and 359 are available in instances where the GP or participating nurse practitioner initiates a review of the plan provided under item 291, usually where the current plan is not achieving the anticipated outcome. It is expected that when a plan is reviewed, any modifications necessary will be made.
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Referred Patient Assessment and Management Plan Guidelines
Note: This information is provided as a guide only and each case should be addressed according to a patient's individual needs. An electronic version of the Guidelines is available on the RANZCP website at www.ranzcp.org
REFERRED PATIENT ASSESSMENT AND MANAGEMENT PLAN
- The following content outline is indicative of what would usually be sent back to GPs or participating nurse practitioner.
- The Management plan should address the specific questions and issues raised by the GP or participating nurse practitioner
- In most cases the patient is usually well known by the GP or participating nurse practitioner
History and Examination
This should focus on the presenting symptoms and current difficulties, including precipitating and ongoing stresses; and only briefly mention any relevant aspects of the patient's family history, developmental history, personality features, past psychiatric history and past medical history.
It should contain a comprehensive relevant Mental Status Examination and any relevant pathology results if performed.
It should summarise any psychological tests that were performed as part of the assessment.
A diagnosis should be made either using ICD 10 or DSM IV classification. In some cases the diagnosis may differ from that stated by the GP or participating nurse practitioner, and an explanation of why the diagnosis differs should be included.
A brief integrated psychiatric formulation focussing on the biological, psychological and physical factors. Any precipitant and maintaining factors should be identified including relevant personality factors. Protective factors should also be noted. Issues of risk to the patient or others should be highlighted.
1. Education - Include a list of any handout material available to help people understand the nature of the problem. This includes recommending the relevant RANZCP consumer and carer clinical practice guidelines.
2. Medication recommendations - Give recommendations for immediate management including the alternatives or options. This should include doses, expected response times, adverse effects and interactions, and a warning of any contra-indicated therapies.
3. Psychotherapy - Recommendations should be given on the most appropriate mode of psychotherapy required, such as supportive psychotherapy, cognitive and behavioural psychotherapy, family or relationship therapy or intensive explorative psychotherapy. This should include recommendations on who should provide this therapy.
4. Social measures - Identify issues which may have triggered or are contributing to the maintenance of the problem in the family, workplace or other social environment which need to be addressed, including suggestions for addressing them.
5. Other non medication measures - This may include other options such as life style changes including exercise and diet, any rehabilitation recommendations, discussion of any complementary medicines, reading recommendations, relationship with other support services or agencies etc.
6. Indications for re-referral - It is anticipated that the majority of patients will be able to be managed effectively by the GP or participating nurse practitioner using the plan. If there are particular concerns about the possible need for further review, these should be noted.
7. Longer term management - Provide a longer term management plan listing alternative measures that might be taken in the future if the clinical situation changes. This might be articulated as a relapse signature and relapse drill, and should include drug doses and other indicated interventions, expected response times, adverse effects and interactions.
Initial Consultation for a NEW PATIENT (item 296 in rooms, item 297 at hospital, item 299 for home visits and 361 for telepsychiatry)
The rationale for items 296 - 299 and 361 is to improve access to psychiatric services by encouraging an increase in the number of new patients seen by each psychiatrist, while acknowledging that ongoing care of patients with severe mental illness is integral to the role of the psychiatrist. Referral for items 296 - 299 and 361 may be from a participating nurse practitioner, medical practitioner practising in general practice, a specialist or another consultant physician.
It is intended that either item 296, 297, 299 or 361 will apply once only for each new patient on the first occasion that the patient is seen by a consultant psychiatrist, unless the patient is referred by a medical practitioner practising in general practice or participating nurse practitioner for an assessment and management plan, in which case the consultant psychiatrist, if he or she agrees that the patient is suitable for management in a general practice setting, will use item 291 where an assessment and management plan is provided to the referring practitioner.
There may be particular circumstances where a patient has been referred by a GP or participating nurse practitioner to a consultant psychiatrist for an assessment and management plan, but it is not possible for the consultant psychiatrist to determine in the initial consultation whether the patient is suitable for management under such a plan. In these cases, where clinically appropriate, item 296, 297, 299 or 361(for a new patient) or 300-308 (for continuing patients) may be used and item 291 may be used subsequently, in those circumstances where the consultant psychiatrist undertakes a consultation (in accordance with the item requirements) and provides the referring practitioner with an assessment and management plan. It is not generally intended that item 296, 297, 299 or 361 will be used in conjunction with, or prior to, item 291.
Use of items 296 - 299 and 361 by one consultant psychiatrist does not preclude them being used by another consultant psychiatrist for the same patient.
Items 300 - 308 are available for consultations in consulting rooms other than those provided under item 296, and items 291, 293 and 359. Similarly time tiered items remain available for hospital, home visits and telepsychiatry. These would cover a new course of treatment for patients who have already been seen by the consultant psychiatrist in the preceding 24 months as well as subsequent consultations for all patients.
Referral to Allied Mental Health Professionals (for new and continuing patients)
To increase the clinical treatment options available to psychiatrists and paediatricians for which a Medicare benefit is payable, patients with an assessed mental disorder (dementia, delirium, tobacco use disorder and mental retardation are not regarded as mental disorders for the purposes of these items) may be referred, to an allied mental health professional for a total of ten individual allied mental health services in a calendar year. The ten services may consist of: psychological therapy services (items 80000 to 80015) - provided by eligible clinical psychologists; and/or focussed psychological strategies - allied mental health services (items 80100 to 80115; 80125 to 80140; 80150 to 80165) - provided by eligible psychologists, occupational therapists and social workers.
Referrals from psychiatrists and paediatricians to an allied mental health professional must be made from eligible Medicare services. For specialist psychiatrists and paediatricians these services include any of the specialist attendance items 104 through 109. For consultant physician psychiatrists the relevant eligible Medicare services cover any of the consultant psychiatrist items 293 through 370; while for consultant physician paediatricians the eligible services are consultant physician attendance items 110 through 133.
Within the maximum service allocation of ten services, the allied mental health professional can provide one or more courses of treatment. For the purposes of these services, a course of treatment will consist of the number of services stated in the patient's referral (up to a maximum of six in any one referral). These services should be provided, as required, for an initial course of treatment (a maximum of six services but may be less depending on the referral and patient need) to a maximum of ten services per calendar year.
While such referrals are likely to occur for new patients seen under items 296 - 299 and 361, they are also available for patients at any point in treatment (from items 293 to 370), as clinically required, under the same arrangements and limitations as outlined above. The referral may be in the form of a letter or note to an eligible allied health professional signed and dated by the referring practitioner.
There is provision for a further referral for up to an additional six individual services to be provided in exceptional circumstances (to a maximum total of 16 individual services per patient from 1 March 2012 to 31 December 2012).
Exceptional circumstances apply where there has been a significant change in the patient's clinical condition or care circumstances which make it appropriate and necessary to increase the maximum number of services. In such cases, the patient's referral should be annotated to briefly indicate the reason why the additional allied mental health services were required in excess of the ten individual services permitted within a calendar year. The referral may be a letter or note to an eligible allied health professional signed and dated by the referring practitioner.
Note: Patients will be able to receive an additional six individual allied mental health services under exceptional circumstances from 1 March 2012 to 31 December 2012. From 1 January 2013 the number of individual allied mental health services for which a person can receive a Medicare rebate will be ten services per calendar year.
Patients will also be eligible to claim up to ten services within a calendar year for group therapy services involving 6-10 patients to which items 80020 (psychological therapy - clinical psychologist), 80120 (focussed psychological strategies - psychologist), 80145 (focussed psychological strategies - occupational therapist) and 80170 (focussed psychological strategies - social worker) apply. These group services are separate from the individual services and do not count towards the ten individual services per calendar year maximum associated with those items.
- Assist - Addition/Deletion of (Assist.)
- Amend - Amended Description
- Anaes - Anaesthetic Values Amended
- Emsn - EMSN Change
- Fee - Fee Amended
- Renum - Item Number Change (renumbered)
- New - New Item
- NewMin - New Item (previous Ministerial Determination)
- Qfe - QFE Change