Medicare Benefits Schedule - Item 386

Professional attendance at consulting rooms or hospital by a consultant occupational physician in the practice of the consultant occupational physician's specialty of occupational medicine following referral of the patient to the consultant occupational physician by a referring practitioner-each attendance after the first in a single course of treatment

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.0.33, AN.0.70, AN.3.1 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $144.15

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Attendances by consultant occupational physicians will attract Medicare benefits only where the attendance relates to one or more of the following:

(i) evaluation and assessment of a patient's rehabilitation requirements where the patient presents with an accepted medical condition(s) which may be affected by the consultant occupational physician's working environment or employability; or

(ii) management of accepted medical condition(s) which may affect a patient's capacity for continued employment or return to employment following a non-compensable accident, injury or ill-health; or

(iii) evaluation and opinion and/or management of a patient's medical condition(s) where causation may be related to acute or chronic exposures from scientifically accepted environmental hazards or toxins.

Related Items: 385 386 387 388

Medicare benefits are not payable for items 105, 116, 119, 386, 2806, 2814, 3010, 3014, 6009, 6011, 6013, 6015, 6019, 6052, 16404, 91823, 91825, 91826, 91833, 91836, 92611, 92612, 92613 and 92618 when claimed in association with an item in group T8 with a schedule fee of $330.20 or more.

The restriction applies when the procedure is performed by the same practitioner, on the same patient, on the same day.

Related Items: 105 116 119 386 2806 2814 3010 3014 6009 6011 6013 6015 6019 6052 16404 91823 91825 91826 91833 91836 92611 92612 92613 92618

The current regulations prohibit the payment of Medicare benefits for subsequent attendance items 105, 116, 119, 386, 2806, 2814, 3010, 3014, 6009 to 6015, 6019, 6052, 16404, 91823, 91825, 91826, 91833, 91836, 92611, 92612, 92613 and 92618 if a claim is made for any Group T8 item (30001-50952) with a schedule fee of equal to or greater than $330.20 on the same day. Non-compliance with the regulations can result in a referral to an appropriate regulatory body – such as the Professional Services Review. Subsequent attendance items (111, 117, and 120) can only be claimed on the same day as Group T8 items with schedule fees of equal to or greater than $330.20, if the procedure is urgent and not able to be predicted prior to the commencement of the attendance.  It is therefore expected that these items would be claimed only in exceptional circumstances.

Subsequent attendance item 115 can only be claimed, if the nature of the attendance was not able to be predicted prior to the procedure. 

Item 115 should not be claimed if the consultation relates to the booked Group T8 procedure.  Any consultation component related to the booked Group T8 procedure is considered to be covered under the fee for that procedure, if the Schedule fee is $330.20 or more.

Should a component of the consultation be unrelated to the booked T8 procedure and it is considered by the medical practitioner that it would be a clinical risk to defer this consultation then item 115 could be claimable.

It would not be appropriate to claim item 115 if a patient attends for the booked operation, and prior to surgery an examination is conducted relevant to performing that procedure; together with a discussion of the outcomes and aftercare. If the consultation extends beyond this; including the development of a management plan involving a broader diagnosis, prognosis, associated treatments and follow-up; then it could be appropriate to claim item 115.

In claiming item 115, the specialist or consultant physician must be satisfied that it would be a clinical risk to defer the consultation for the patient at this time.

Where item 115 is claimed, the records for the consultation should clearly identify why the consultation is considered necessary for the patient including the clinical risk to defer the consultation.

Related Items: 105 115 116 119 386 2806 2814 3010 3014 6009 6011 6013 6015 6019 6052 16404 91823 91825 91826 91833 91836 92610 92611 92612 92613