Medicare Benefits Schedule - Item 82005

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Category 8 - MISCELLANEOUS SERVICES

82005

82005 - Additional Information

Item Start Date:
01-Jul-2008
Description Start Date:
01-Jan-2013
Schedule Fee Start Date:
01-Nov-2012

Group
M10 - Autism, Pervasive Developmental Disorder And Disability Services

SPEECH PATHOLOGY

Speech pathology health service provided to a child, aged under 13 years, by an eligible speech pathologist where:


(a) the child is referred by an eligible practitioner for the purpose of assisting the practitioner with their diagnosis of the child;

or

(b) the child is referred by an eligible practitioner for the purpose of contributing to the child's pervasive developmental disorder

     (PDD) or disability treatment plan, developed by the practitioner; and

(c) for a child with PDD, the eligible practitioner is a consultant physician in the practice of his or her field of psychiatry or paediatrics; or for a child with disability, the eligible practitioner is a specialist, consultant physician or general practitioner: and

(d) the speech pathologist attending the child is registered with the Department of Human Services as meeting the credentialing requirements for provision of these services; and

(e) the child is not an admitted patient of a hospital; and

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

(g) the service lasts at least 50 minutes in duration.


These items are limited to a maximum of four services per patient, consisting of any combination of the following items

─ 82000, 82005, 82010 and 82030

Fee: $87.95 Benefit: 85% = $74.80

(See para MN.10.1 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $263.85


Associated Notes

Category 8 - MISCELLANEOUS SERVICES

MN.10.1

Provision of Autism, Pervasive Developmental Disorder or Disability Services by Allied Health Professionals - (Items 82000 to 82035)

Eligible patients

MBS items 82000 to 82035 provide Medicare-rebateable allied health services to children with autism or any other pervasive developmental disorder (PDD) through the Helping Children with Autism program, and to children with an eligible disability through the Better Start for Children with Disability program.  Children with both autism/PDD and an eligible disability can access either program, but not both.

The conditions classified as PDD in 2008 for the purposes of these services were informed by the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), Washington, DC, American Psychiatric Association, 2000.

'Eligible disabilities' for the purpose of these services means any of the following conditions:

(a)        sight impairment that results in vision of less than or equal to 6/18 vision or equivalent field loss in the better eye, with correction.

(b)        hearing impairment that results in:

(iii)       a hearing loss of 40 decibels or greater in the better ear, across 4 frequencies; or

(iv)       permanent conductive hearing loss and auditory neuropathy.

(c)        deafblindness

(d)        cerebral palsy

(e)        Down syndrome

(f)        Fragile X syndrome

(g)        Prader-Willi syndrome

(h)        Williams syndrome

(i)         Angelman syndrome

(j)         Kabuki syndrome

(k)        Smith-Magenis syndrome

(l)         CHARGE syndrome

(m)      Cri du Chat syndrome

(n)        Cornelia de Lange syndrome

(o)        microcephaly if a child has:

(iii)       a head circumference less than the third percentile for age and sex; and

(iv)       a functional level at or below 2 standard deviations below the mean for age on a standard developmental test, or an IQ score of less than 70 on a standardised test of intelligence.

(p)        Rett's disorder

"standard developmental test" refers to the Bayley Scales of Infant Development or the Griffiths Mental Development Scales; "standardised test of intelligence" means the Wechsler Intelligence Scale for Children (WISC) or the Wechsler Preschool and Primary Scale of Intelligence (WPPSI).  It is up to the clinical judgement of the diagnosing practitioner if other tests are appropriate to be used.

Allied health services available under Medicare

Items are available for assessment/diagnosis services, the results of which can contribute to development of a treatment and management plan by the referring medical practitioner, and for treatment services. 

The assessment/diagnosis items (82000, 82005, 82010, 82030) can be accessed when:

¿           a child with autism/PDD is aged under 13 years and referred by an eligible consultant psychiatrist or paediatrician; or

¿           a child with an eligible disability is aged under 13 years and referred by a specialist, consultant physician or GP. 

The treatment items (82015, 82020, 82025 and 82035) can be accessed when:

¿           A child with autism/PDD is aged under 15 years and a treatment and management plan has been put in place for them before their 13th birthday, and they have been referred by an eligible consultant psychiatrist or paediatrician.

¿           A child with an eligible disability is aged under 15 years and a treatment and management plan has been put in place for them before their 13th birthday, and they have been referred by a specialist, consultant physician or GP.

The allied health assessment and treatment services can be provided by eligible audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists.

Number of assessment services

Medicare rebates are available for up to four services in total per eligible child, to assist with assessment and diagnosis and development of a treatment plan.  The four services may consist of any combination of items 82000, 82005, 82010 and 82030.  It is the responsibility of the referring practitioner to allocate these services in keeping with the child's individual needs and to refer the child to appropriate allied health professional(s) accordingly.

These services will not attract a Medicare rebate unless a referral has been made by a consultant psychiatrist (using items 296-370) or paediatrician (using items 110-131) for a child with autism/PDD, or by a specialist or consultant physician (using items 104-131 or 296-370 excluding item 359) or GP (using items 3-51) for a child with a disability.

Number of treatment services

Medicare rebates are available for up to twenty allied health treatment services in total per eligible child.  The twenty services may consist of any combination of items 82015, 82020, 82025 and 82035.  It is the responsibility of the referring practitioner to allocate these services in keeping with the child's individual treatment needs and to refer the child to appropriate allied health professional(s) accordingly.

These services will not attract a Medicare rebate unless referral has been made by a consultant psychiatrist (using item 289) or paediatrician (using item 135) for children with autism/PDD, or by a specialist or consultant physician (using item 137) or a GP for disability (using item 139) for children with disability.

Service length and type

Services under these items must be for the time period specified within the item descriptor.  The allied health professional must personally attend the child.

A child may receive up to four Medicare eligible services from an allied health professional on the same day.

It is anticipated that professional attendances at places other than consulting rooms would be provided where treatment in other environments is necessary to achieve therapeutic outcomes. 

It is also expected that participating allied health providers will deliver treatment under these items that is consistent with the autism/PDD or disability treatment plan prepared by the medical practitioner, and is in keeping with commonly established autism/PDD or disability interventions as practised by their profession and appropriate for the age and particular needs of the child being treated.

Eligible allied health professionals

Allied health professionals providing services under these items must be registered with the Department of Human Services.  To register with the Department of Human Services to provide these services, an allied health professional must meet the specific eligibility requirements detailed below:

¿           Audiologist must be either a 'Full Member' of the Audiological Society of Australia Inc (ASA), who holds a 'Certificate of Clinical Practice' issued by the ASA; or an 'Ordinary Member - Audiologist' or 'Fellow Audiologist' of the Australian College of Audiology (ACAud).

¿           Occupational Therapist must be registered with the Occupational Therapy Board of Australia.

¿           Optometrist must be registered as an optometrist or optician under a law of a State or an internal Territory that provides for the registration of optometrists or opticians, and be a participating optometrist.

¿           Orthoptist must be registered with the Australian Orthoptic Board and have a Certificate of Currency; and be a member of Orthoptics Australia.

¿           Physiotherapist must be registered with the Physiotherapy Board of Australia.

¿           Psychologist must hold General Registration with the Psychology Board of Australia.

¿           Speech Pathologist must be a 'Practising Member' of Speech Pathology Australia.

In addition to meeting the above mentioned credentialing requirements, it is expected that eligible providers will "self-select" for the autism/PDD and disability items (i.e. possess the skills and experience appropriate for provision of these services and be oriented to work with children with autism/PDD or disability).

Referral requirements

An allied health professional wanting to provide any of the items 82000-82035 must be in receipt of a current referral provided by an eligible medical practitioner.  Referrals are only valid when prerequisite MBS services have been provided.

An eligible allied health professional can provide assessment items (82000, 82005, 82010 and 82030) to a child under the Helping Children with Autism program when:

¿           the child has previously been provided with any MBS service covering items 110 through 131 inclusive by a consultant paediatrician; or

¿           the child has previously been provided with any MBS service covering items 296 through 370 (excluding item 359) inclusive by a consultant psychiatrist.

            

An eligible allied health professional can provide assessment items (82000, 82005, 82010 and 82030) to a child under the Better Start for Children with Disability program when:

¿           the child has previously been provided with any MBS service covering items 104 through 131 inclusive, or items 296 through 370 (excluding item 359) inclusive by a specialist or consultant physician; or

¿           the child has previously been provided with any MBS service covering items 3 through 51 by a GP.

An eligible allied health professional can provide treatment items (82015-82025 and 82035) to a child under the Helping Children with Autism program when:

¿           the child has previously been provided with a treatment plan (item 135) by a consultant paediatrician; or

¿           the child has previously been provided with a treatment plan (item 289) by a consultant psychiatrist.

An eligible allied health professional can provide treatment items (82015-82025 and 82035) to a child under the Better Start for Children with Disability program when:

¿           the child has previously been provided with a treatment plan (MBS item 137) by a specialist or consultant physician; or

¿           the child has previously been provided with a treatment plan (MBS item 139) by a GP.

If the referring service has not yet been claimed, the Department of Human Services (DHS) will not be aware of the child's eligibility and Medicare benefits cannot be paid.  DHS will be able to confirm whether a relevant MBS service has been claimed and/or the number of allied health services already claimed by the child.  Allied health professionals can call the DHS provider line on 132 150.  Parents and carers can call the patient information line on 132 011.

It is recommended that allied health professionals retain the referral for 24 months from the date the service was rendered for Medicare auditing purposes.

Referring medical practitioners are not required to use a specific form to refer patients for these services.  The referral may be a letter or note to an eligible allied health professional signed and dated by the referring practitioner.

Referral validity

Medicare benefits are available for up to four allied health assessment and diagnosis services and up to twenty allied health treatment services per patient in total. 

Patients will require a separate referral for each allied health professional they are referred to and they will also need new referrals for each new course of treatment.

A course of treatment for the allied health treatment services consists of the number of allied health services stated on the child's referral.  This enables the referring practitioner to consider a report from the allied health professional(s) about the services provided to the child, and the need for further treatment.

Within the maximum service allocation of twenty services for the treatment items, the allied health professional(s) can provide one or more courses of treatment.  Up to 4 services may be provided to the same child on the same day.

Reporting requirements

A written report must be provided to the referring medical practitioner by the allied health professional(s) after having provided the assessment and diagnosis and development of a treatment plan service(s) to the child.

On completion of a course of treatment, the eligible audiologist, occupational therapist, optometrist, orthoptist, physiotherapist, psychologist and speech pathologist must provide a written report to the referring medical practitioner which includes information on:

¿           treatment provided;

¿           recommendations on future management of the child's disorder; and

¿           any advice provided to third parties (e.g. parents, schools).

A written report must also be provided to the referring medical practitioner at the completion of any subsequent course(s) of treatment provided to the child.

Further information

For more information refer to the MBS online website or  the MBS Primary Care Items information page. information page.

Related Items: 82000 82005 82010 82015 82020 82025 82030 82035


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