Medicare Benefits Schedule - Item 81100

DIABETES EDUCATION SERVICE - ASSESSMENT FOR GROUP SERVICES

Diabetes education health service provided to a person by an eligible diabetes educator for the purposes of ASSESSING a person's suitability for group services for the management of type 2 diabetes, including taking a comprehensive patient history, identifying an appropriate group services program based on the patient's needs, and preparing the person for the group services, if:

(a)    the service is provided to a person who has type 2 diabetes; and

(b)  the person is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under a shared care plan or a GP Management Plan or, if the person is a resident of an aged care facility, their medical practitioner has contributed to a multidisciplinary care plan; and  

(c)    the person is referred to an eligible diabetes educator by the medical practitioner using a referral form that has been issued by the Department of Health, or a referral form that contains all the components of the form issued by the Department; and

(d)    the person is not an admitted patient of a hospital; and

(e)    the service is provided to the person individually and in person; and

(f)    the service is of at least 45 minutes duration; and

(g)    after the service, the eligible diabetes educator gives a written report to the referring medical practitioner mentioned in paragraph (c); and

(h)    in the case of a service in respect of which a private health insurance benefit is payable - the person who incurred the medical expenses in respect of the service has elected to claim the Medicare benefit in respect of the service, and not the private health insurance benefit.

Benefits are payable once only in a calendar year for this or any other Assessment for Group Services item (including services to which items 81100, 81110, 81120, 93284, 93286, 93606, 93607 and 93608 apply).

Fee: $84.45 Benefit: 85% = $71.80

(See para MN.9.1, MN.9.2, MN.9.3, MN.9.4, MN.9.6, MN.9.7 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $253.35

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MBS items (81100 to 81125) are available for group allied health services for patients with type 2 diabetes.  These items apply to services provided by eligible diabetes educators, exercise physiologists and dietitians, on referral from a GP or medical practitioner.

Services available under these items are in addition to the five individual allied health services available to patients each calendar year (refer to items 10950 to 10970).

To be eligible for these services, the patient must have in place one of the following:

• a GP Management Plan (GPMP) (GP item 721 or medical practitioner item 229); OR

• for a resident of a residential aged care facility, the GP or medical practitioner must have contributed to, or contributed to a review of, a care plan prepared for them by the facility (GP item 731 or medical practitioner item 232). [Note: Generally, residents of an aged care facility rely on the facility for assistance to manage their type 2 diabetes. Therefore, the resident may not need to be referred for group allied health services under these items, as the self-management approach offered in group services may not be appropriate.]; OR

• a Health Care Home shared care plan.

Unlike the individual allied health services under items 10950 to 10970, there is no additional requirement for a Team Care Arrangement (GP item 723 or medical practitioner item 230) in order for the patient to be referred for group allied health services.

Once the patient has been referred by their GP or medical practitioner, a diabetes educator, exercise physiologist or dietitian will conduct an individual assessment (under items 81100, 81110 or 81120).  A maximum of one (1) assessment service is available per calendar year. After assessment, the patient may receive up to eight (8) group services per calendar year from an eligible diabetes educator, exercise physiologist and/or dietitian (under items 81105, 81115 and 81125).  A collaborative approach, where diabetes educators, exercise physiologists and dietitians work together to develop group service programs in their local area, is encouraged.

Related Items: 81100 81105 81110 81115 81120 81125

Patients must be referred by their GP to an eligible allied health professional (diabetes educator, exercise physiologist or dietitian) who will undertake an individual assessment of their suitability for a group services program (under item 81100, 81110 or 81120). 

When referring patients, GPs must use a referral form that has been issued by the Australian Government Department of Health or a Health Care Home shared care plan or a form that contains all the components of this form.  The form issued by the department is available at http://www.health.gov.au/mbsprimarycareitems (click on the link for group allied health services). 

GPs are also encouraged to provide a copy of the relevant part of the patient's care plan to the allied health professional. 

Health Care Home shared care plan

A Health Care Home shared care plan means a written plan that is prepared for a patient enrolled at a Health Care Home trial site; is prepared by a medical practitioner (including a general practitioner but not including a specialist or consultant physician) who is leading the patient's care at the Health Care Home trial site; and includes:  an outline of the patient's agreed current and long-term goals; the person or people responsible for each activity; arrangements to review the plan by a day mentioned in the plan; and if authorised by the patient, arrangements for the transfer of information between the medical practitioner and other health care providers supporting patient care about the patient's condition or conditions and treatment.

Related Items: 81100 81105 81110 81115 81120 81125

Items 81100 to 81125 only apply to services provided by eligible diabetes educators, exercise physiologists and dietitians who are registered with the Department of Human Services.  If providers are already registered with the Department of Human Services to use item 10951, 10953 or 10954, they do not need to register separately for items 81100 to 81125.  Eligibility criteria are as follows: 

Diabetes educator: must be a 'credentialed diabetes educator' (CDE) as credentialed by the Australian Diabetes Educators Association (ADEA). 

Exercise physiologist: must be an 'accredited exercise physiologist' as accredited by Exercise and Sports Science Australia (ESSA). 

Dietitian: must be an 'accredited practising dietitian' as recognised by the Dietitians Association of Australia (DAA). 

The Department of Human Services registration forms may be obtained from the Department of Human Services on 132 150 or at the Department of Human Services' website.

Related Items: 81100 81105 81110 81115 81120 81125

An assessment service is provided by a diabetes educator (item 81100), an exercise physiologist (item 81110) or a dietitian (item 81120), on referral from a GP. 

The purpose of this service is to undertake an individual assessment and determine the patient's suitability for a group services program.  It involves taking a comprehensive patient history and identification of individual goals.  This may also provide an opportunity to identify any patient who is likely to be unsuitable for group services. 

Number of services per year

Patients are eligible for a maximum of one assessment for group services (item 81100 or 81110 or 81120) per calendar year.  If more than one assessment service is provided in a calendar year, the subsequent service/s will not attract a Medicare rebate and the MBS Safety Net arrangements will not apply to costs incurred by the patient for the service/s. 

If there is any doubt about a patient's eligibility for items 81100, 81110 or 81120, the allied health professional should contact the Department of Human Services to confirm the number of assessment services already claimed by the patient in the calendar year.  Allied health professionals can call the Department of Human Services on 132 150 to check this information. 

Referral form

The GP must refer the patient using the Referral form for group allied health services under Medicare for patients with type 2 diabetes or a Health Care Home shared care plan or a form that contains all the components of this form.  The form issued by the department is available at http://www.health.gov.au/mbsprimarycareitems (click on the link for group allied health services). 

The allied health professional undertaking the assessment service will need to complete Part B of this form, and the patient will then need to present this form to the provider/s of group services.  

Health Care Home shared care plan

A Health Care Home shared care plan means a written plan that is prepared for a patient enrolled at a Health Care Home trial site; is prepared by a medical practitioner (including a general practitioner but not including a specialist or consultant physician) who is leading the patient's care at the Health Care Home trial site; and includes:  an outline of the patient's agreed current and long-term goals; the person or people responsible for each activity; arrangements to review the plan by a day mentioned in the plan; and if authorised by the patient, arrangements for the transfer of information between the medical practitioner and other health care providers supporting patient care about the patient's condition or conditions and treatment. 

Length of service

This service must be of at least 45 minutes duration and provided to an individual patient.  The allied health professional must personally attend the patient. 

Reporting requirements

On completion of the assessment service, the allied health professional must provide a written report back to the referring GP outlining the assessment undertaken, whether the patient is suitable for group services and, if so, the nature of the group services to be delivered.

Related Items: 81100 81110 81120

Retention of Referral Form for the Department of Human Services Audit Purposes

It is recommended that Allied health professionals retain a copy of the referral form for 24 months from the date the service was rendered (for the Department of Human Services auditing purposes). 

Publicly funded services

Items 81100 - 81125 do not apply for services that are provided by any other Commonwealth or state-funded services or provided to an admitted patient of a hospital.  However, where an exemption under subsection 19(2) of the Health Insurance Act 1973 has been granted to an Aboriginal Community Controlled Health Service or a state/territory government health clinic, items 81100-81125 can be claimed for services provided by eligible allied health professionals salaried by, or contracted to, service or health clinic.  All requirements of the relevant item must be met, including registration of the allied health professional with the Department of Human Services.  These services must also be bulk billed. 

Private health insurance

Patients need to decide if they will use Medicare or their private health insurance ancillary cover to pay for these services.  Patients cannot use their private health insurance ancillary cover to 'top up' the Medicare rebate paid. 

Out-of-pocket expenses and Medicare Safety Net

Allied health professionals are free to determine their own fees for the professional service.  Charges in excess of the Medicare benefit for the allied health items are the responsibility of the patient.  However, such out of pocket costs will count toward the Medicare Safety Net for that patient.

Related Items: 81100 81105 81110 81115 81120 81125

Further information about these items is available on the Department of Health's website at www.health.gov.au/mbsprimarycareitems

Related Items: 81100 81105 81110 81115 81120 81125