Medicare Benefits Schedule - Item 16404

Search Results for Item 16404

View Associated Notes

Category 3 - THERAPEUTIC PROCEDURES

16404

16404 - Additional Information

Item Start Date:
01-Jan-2010
Description Updated:
01-Jan-2024
Schedule Fee Updated:
01-Nov-2023

Group
T4 - Obstetrics

Professional attendance at consulting rooms or a hospital by a specialist in the practice of the specialist’s specialty of obstetrics after referral of the patient to the specialist—an attendance after the initial attendance in a single course of treatment

Fee: $47.35 Benefit: 75% = $35.55 85% = $40.25

(See para AN.0.70, AN.3.1, TN.4.2 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $39.20


Associated Notes

Category 1 - PROFESSIONAL ATTENDANCES

AN.0.70

Limitation of items—certain attendances by specialists and consultant physicians

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

Category 1 - PROFESSIONAL ATTENDANCES

AN.3.1

Subsequent attendance items

 

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

Category 3 - THERAPEUTIC PROCEDURES

TN.4.2

Items for Initial and Subsequent Obstetric Attendances (Items 16401 and 16404)

16401 and 16404 replace items 104 and 105 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 postnatal care provided to the patient subsequent to the expiration of normal aftercare period.  Item 16500 is still claimed for routine antenatal attendances.  These items are subject to Extended Medicare Safety Net caps.

Related Items: 16401 16404


Legend

  • 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