Medicare Benefits Schedule - Item 90250

Search Results for Item 90250

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Category 1 - PROFESSIONAL ATTENDANCES

90250

90250 - Additional Information

Item Start Date:
01-Nov-2019
Description Updated:
01-Mar-2021
Schedule Fee Updated:
01-Jul-2020

Group
A36 - Eating Disorder Services
Subgroup
1 - Preparation of eating disorder treatment and management plans: general practitioners and non specialist medical practitioners

Professional attendance by a general practitioner to prepare an eating disorder treatment and management plan, lasting at least 20 minutes but less than 40 minutes.

Fee: $73.95 Benefit: 100% = $73.95

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $221.85


Associated Notes

Category 1 - PROFESSIONAL ATTENDANCES

AN.36.1

Eating Disorders General Explanatory Notes

Eating Disorders General Explanatory Notes (items 90250-90257, 90260-90269 and 90271-90282)


This note provides a general overview of the full range of 1 November 2019 eating disorders Items and supporting information more specifically on the Category 1 – Professional Attendances: Group A36 – Eating Disorders Services (90250-90257, 90260-90269 and 90271-90282).

It includes an overview of the items, model of care, patient eligibility, and inks to other guidance and resources.

Overview

All 1 November 2019 Eating Disorders new items:

The Eating Disorders items define services for which Medicare rebates are payable where service providers undertake assessment and management of patients with a diagnosis of anorexia nervosa and patients with other specified eating disorder diagnoses who meet the eligibility criteria (see – patient eligibility). It is expected that there will be a multidisciplinary approach to patient management through these items.

The items mean eligible patients are able to receive a Medicare rebate for development of an eating disorders treatment plan by a medical practitioner in general practice (Group A36, subgroup 1), psychiatry or paediatrics (Group A36, subgroup 2). Patients with an eating disorders treatment and management plan (EDP) will be eligible for comprehensive treatment and management services for a 12 month period, including:

  • Up to 20 dietetic services under items 10954, 82350 and 82351.
  • Up to 40 eating disorder psychological treatment services (EDPT service).  
  • Review and ongoing management services to ensure that the patient accesses the appropriate level of intervention (Group A36, subgroup 3).

An EDPT service includes mental health treatment services which are provided by an allied health professional or a medical practitioner in general practice with appropriate mental health training. These treatment services include:

  • Medicare mental health treatment services currently provided to patients under the ‘Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS (‘Better Access’) initiative.
    • This includes medical practitioner items 2721, 2723, 2725, 2727, 283, 285, 286, 287, 371, 372; and
    • This includes allied health items in Groups M6 and M7 of Category 8; and
  • new items for EDPT services provided by suitably trained medical practitioners in general practice (items 90271, 90272, 90273, 90274, 90275, 90276, 90277, 90278, 90279, 90280, 90281, 90282)
  • new items for EDPT services provided by eligible clinical psychologists (items 82352-82359), eligible psychologists (items 82360-82367), eligible occupational therapists (items 82368-82375) and eligible social workers (items 82376-82383)
     

For the purpose of the 40 EDPT count; eating disorder psychological treatment service includes a service under provided under the following items: 90271, 90272, 90273, 90274, 90275, 90276, 90277, 90278, 90279, 90280, 90281, 90282, 2721, 2723, 2725, 2727, 283, 285, 286, 287, 371, 372 and items in Groups M6, M7 and M16 (excluding items 82350 and 82351).

For any particular patient, an eating disorder treatment and management plan expires at the end of a 12 month period following provision of that service. After that period, a patient will require a new EDP to continue accessing EDPT services.

Patient Eligibility

The eating disorder items are available to eligible patients in the community. These items do not apply to services provided to admitted (in-hospital) patients.

The referring practitioner is responsible for determining that a patient is eligible for an EDP and therefore EDPT and dietetic services.

‘Eligible patient’ defines the group of patients who can access the new eating disorder services. There are two cohorts of eligible patients.

  1. Patients with a clinical diagnosis of anorexia nervosa; or
  2. Patients who meet the eligibility criteria (below), and have a clinical diagnosis of any of the following conditions:
    1. bulimia nervosa;
    2. binge-eating disorder;
    3. other specified feeding or eating disorder.

The eligibility criteria, for a patient, is:

  1. a person who has been assessed as having an Eating Disorder Examination Questionnaire score of 3 or more; and
  2. the condition is characterised by rapid weight loss, or frequent binge eating or inappropriate compensatory behaviour as manifested by 3 or more occurrences per week; and
  3. a person who has at least two of the following indicators:
    1. clinically underweight with a body weight less than 85% of expected weight where weight loss is directly attributable to the eating disorder;
    2. current or high risk of medical complications due to eating disorder behaviours and symptoms;
    3. serious comorbid medical or psychological conditions significantly impacting on medical or psychological health status with impacts on function;
    4. the person has been admitted to a hospital for an eating disorder in the previous 12 months;
    5. inadequate treatment response to evidence based eating disorder treatment over the past six months despite active and consistent participation.

Practitioners should have regard to the relevant diagnostic criteria set out in the Diagnostic and Statistical Manual of the American Psychiatric Association – Fifth Edition (DSM-5)

Practitioners can access the Eating Disorder Examination Questionnaire at https://www.credo-oxford.com/pdfs/EDE_17.0D.pdf

The Eating Disorders Items Stepped Model of Care

The eating disorder items incorporate a ‘stepped model’ for best practice care for eligible patients with eating disorders that comprise:

  • assessment and treatment planning
  • provision of and/or referral for appropriate evidence based eating disorder specific treatment services by allied mental health professionals and provision of services by dietitians
  • review and ongoing management items to ensure that the patient accesses the appropriate level of intervention.

The Stepped Model

‘STEP 1’ – PLANNING (trigger eating disorders pathway) 90250-90257 and 90260-90263

An eligible patient receives an eating disorder plan (EDP) developed by a medical practitioner in general practice (items 90250-90257), psychiatry (items 90260-90262) or paediatrics (items 90261-90263).

 ‘STEP 2’ – COMMENCE INITIAL COURSE OF TREATMENT (psychological & dietetic services)

Once an eligible patient has an EDP in place, the 12 month period commences, and the patient is eligible for an initial course of treatment up to 20 dietetic services and 10 eating disorder psychological treatment (EDPT) services. A patient will be eligible for an additional 30 EDPT services in the 12 month period, subject to reviews from medical practitioners to determine appropriate intensity of treatment.

 ‘STEP 3” – CONTINUE ON INITIAL COURSE OF TREATMENT 90264-90269 (managing practitioner review and progress up to 20 EDPT services)

It is expected that the managing practitioner will be reviewing the patient on a regular, ongoing and as required basis. However, a patient must have a review of the EDP (90264-90269), to assess the patient’s progress against the EDP or update the EDP, before they can access more than 10 EDPT services. This is known as the ‘first review’. The first review should be provided by the patient’s managing practitioner, where possible.

‘STEP 4’ FORMAL SPECIALIST AND PRACTITIONER REVIEW 90266-90269 (continue beyond 20 EDPT services)

A patient must have two additional reviews before they can access more than 20 EDPT services. One review (the ‘second review’) must be performed by a medical practitioner in general practice (who is expected to be the managing practitioner), and the other (the ‘third review’) must be performed by a paediatrician (90267 or 90269) or psychiatrist (90266 or 90268). Should both recommend the patient requires more intensive treatment, the patient would be able to access an additional 10 EDPT services in the 12 month period. These reviews are required to determine that the patient has not responded to treatment at the lower intensity levels.

The patient’s managing practitioner should be provided with a copy of the specialist review.

The specialist review by the psychiatrist or paediatrician can occur at any point before 20 EDPT services. The practitioner should refer the patient for specialist review as early in the treatment process as appropriate. If the practitioner is of the opinion that the patient should receive more than 20 EDPT services, the referral should occur at the first practitioner review (after the first course of treatment) if it has not been initiated earlier.

Practitioners should be aware that the specialist review can be provided via telehealth (90268 and 90269). Where appropriate, provision has been made for practitioner participation on the patient-end of the telehealth consultation.

It is expected that the managing practitioner will be reviewing the patient on a regular, ongoing and as required basis. However, a patient must have a review of the EDP (90264-90269), to assess the patient’s progress against the EDP or update the EDP, before they can access the next course of treatment.

‘STEP 5’ ACCESS TO MAXIMUM INTENSITY OF TREATMENT 90266-90269 (continue beyond 30 EDPT services)

To access more than 30 EDPT treatment services in the 12 month period, patients are required to have an additional review (the ‘fourth review’) to ensure the highest intensity of treatment is appropriate. Subject to this review, a patient could access the maximum of 40 EDPT treatment services in a 12 month period. The fourth review should be provided by the patient’s managing practitioner, where possible. 

An Integrated Team Approach

A patient’s family and/or carers should be involved in the treatment planning and discussions where appropriate. The family can be involved in care options throughout the diagnosis and assessment, and are usually the support unit that help to bridge the gap between initial diagnosis and eating disorder specific treatment.

The National Standards for the safe treatment of eating disorders specify a multi-disciplinary treatment approach that provides coordinated psychological, physical, behavioural, nutritional and functional care to address all aspects of eating disorders. People with eating disorders require integrated inter-professional treatment that is able to work within a framework of shared goals, care plans and client and family information. Frequent communication is required between treatment providers to prevent deterioration in physical and mental health (RANZCP Clinical Guidelines: Hay et al., 2014). Consider regular case conferencing to ensure that the contributing team members are able to work within a shared care plan and with client and carers to achieve best outcomes.

Clinical guidelines and other resources

It is expected that the consultants providing services under these items should have the appropriate skills, knowledge and experience to provide eating disorders treatment. However, there are a number of resources which may be of assistance to practitioners in supporting and developing eating disorders treatment plans, these include:

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

National Eating Disorders Collaboration Eating Disorders: a professional resources for general practitioners available at www.nedc.com.au

Eating Disorders Training

It is expected that practitioners who are providing services under these items have appropriate training, skills and experience in treatment of patients with eating disorders and meet the national workforce core competencies for the safe and effective identification of and response to eating disorders more information available at National Eating Disorders Collaboration

Training Services

Practitioners should contact their professional organisation to identify education and training which may assist to practitioners to gain the skills and knowledge to provide services under these items.

The following organisations provide training which may assist practitioners to meet the workforce competency standards:

  • The Australia and New Zealand Academy of eating disorders (ANZAED) - National
  • InsideOut Institute - National
  • The Victorian Centre of Excellence in Eating Disorders (CEED) - VIC
  • Queensland Eating Disorder Service (QuEDS) - QLD
  • Statewide Eating Disorder Service (SEDS) - SA
  • WA Eating Disorders Outreach & Consultation Service (WAEDOCS) – WA

This list is not exhaustive, but has been included to provide examples on the types of training available which may assist practitioners to upskill in this area.

 

Related Items: 90250 90251 90252 90253 90254 90255 90256 90257 90260 90261 90262 90263 90264 90265 90266 90267 90268 90269 90271 90272 90273 90274 90275 90276 90277 90278 90279 90280 90281 90282

Category 1 - PROFESSIONAL ATTENDANCES

AN.36.2

Eating Disorders Treatment and Management Plans Explanatory Notes

Eating Disorders Treatment and Management Plans Explanatory Notes (items 90250-90257 and 90260-90263)


This note provides information on Eating Disorders Treatment and Management Plan (EDP) items and should be read in conjunction with the Eating Disorders General Explanatory Notes

Eating Disorder Treatment Plan (EDP) items overview

The EDP items define services for which Medicare rebates are payable where practitioners undertake the development of a treatment and management plan for patients with a diagnosis of anorexia nervosa and patients with other specified eating disorder diagnoses who meet the eligibility criteria.

The EDP items trigger eligibility for items which provide delivery of eating disorders psychological treatment (EDPT) services (up to a total of 40 psychological services in a 12 month period) and dietetic services (up to a total of 20 in a 12 Month period).

For any particular patient, an eating disorder treatment and management plan expires at the end of a 12 month period following provision of that service. Eating Disorders treatment services are not available to the patient if the EDP has expired.

Preparation of the EDP must include:

  • discussing the patient’s medical and psychological health status with the patient and if appropriate their family/carer;
  • identifying and discussing referral and treatment options with the patient and their family/carer where appropriate, including identification of appropriate support services;
  • agreeing goals with the patient and their family/carer where appropriate - what should be achieved by the treatment - and any actions the patient will take;
  • planning for the provision of appropriate patient and family/carer education;
  • a plan for crisis intervention and/or for relapse prevention, if appropriate at this stage;
  • making arrangements for required referrals, treatment, appropriate support services, review and follow-up;
  • documenting the results of assessment, patient needs, goals and actions, referrals and required treatment/services, and review date in the patient's plan;
  • Discussing and organising the appropriate reviews throughout the patient’s treatment; and
  • discussing the need for the patient to be reviewed to access a higher intensity of EDPT services  in a 12 month period.
     

Preparing a Medical practitioner in general practice Eating Disorder Treatment & Management Plan (items 90250-90257)

Who can provide the service

Items in subgroup 1 of Group A36 can be rendered by a medical practitioner in general practice. This includes:

  • Medical practitioners who can render a general practitioner service in Group A1 of the MBS (see note AN.0.9 for the types of medical practitioners). These medical practitioners can render a ‘general practitioner’ service for items in subgroup 1 of Group A36.
  • Medical practitioners who are not general practitioners, specialists or consultant physicians. These medical practitioners can render a ‘medical practitioner’ service for items in subgroup 1 of Group A36.

What is Involved - Assess and Plan

It is expected that the practitioner developing the EDP has either performed or reviewed the assessments and examinations required to make a judgement that the patient meets the eligibility criteria for accessing these items.

Items 90250-90257 provide services for development of the eating disorder treatment and management plan. Where a comprehensive physical examination is performed, either on the same occasion or different occasion, the appropriate item could be claimed provided the time taken performing the assessment is not included in the time for producing the plan, or time producing the EDP is not included in the time for assessment.

It is emphasised that it is best practice for the practitioner to perform a comprehensive physical assessment to facilitate ongoing patient management and monitoring of medical and nutritional status.

Patient Assessment

An assessment of a patient with an eating disorders includes:

  • taking relevant history (biological, psychological, social, including family/carer support);
  • eating disorder diagnostic assessment;
  • medical review including physical examination and relevant tests;
  • conducting an assessment of mental state, including identification of comorbid psychiatric conditions;
  • an assessment of eating disorder behaviours;
  • an assessment of associated risk and any medical co-morbidity, including as assessment on how this impacts on the patients functioning and activities of daily living;
  • an assessment of family and/or carer support and
  • administering an outcome measurement tool, except where it is considered clinically inappropriate.


Risk assessment for a patient with an eating disorder should include identification of:

  • medical instability and risk of hospitalisation;
  • level of psychological distress and suicide risk;
  • level of malnourishment;
  • identification of psychiatric comorbidity;
  • level of disability;
  • duration of illness;
  • response to earlier evidence-based eating disorders treatment;
  • level of family/carer support.


It should be noted that the patient's EDP should be treated as a living document for updating as required. In particular, the plan can be updated at any time to incorporate relevant information, such as feedback or advice from other health professionals on the diagnosis or treatment of the patient.

Preparing a Consultant Psychiatrist or Paediatrician Eating Disorder Treatment & Management Plan (90260-90263)

Who can provide the service

Items in subgroup 2 of Group 36 can be rendered by consultant psychiatrists (items 90260 and 90261) and consultant paediatricians (items 90262 and 90263).

What is Involved – Assess and Plan

Items 90260-90263 provide access to specialist assessment and treatment planning. It is expected that items will be a single attendance. However, there may be particular circumstances where a patient has been referred by a GP for an assessment and management plan, but it is not possible for the consultant to determine in the initial consultation whether the patient is suitable for management under such a plan. In these cases, where clinically appropriate, other appropriate consultation items may be used. In those circumstances where the consultant 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 expected that such occurrences would be unusual for the purpose of diagnosis under items 90260 & 90262.

EDP Items 90262 and 90263 provide for provision of video conference attendance, consistent with other video conference services listed in the Table (see AN.36.6 Eating Disorders Telehealth – Consultant psychiatrists or paediatricians).

Patient Assessment

In order to facilitate ongoing patient focussed management, an assessment of the patient must include:

  • administering an outcome measurement tool during the assessment and review stages of treatment, where clinically appropriate. The choice of outcome tool to be used is at the clinical discretion of the practitioner;
  • conducting a mental state examination;
  • taking relevant history (biological, psychological, behavioural, nutritional, social);
  • assessing associated risk and any co-morbidity; and
  • making a psychiatric diagnosis for conditions meeting the eligibility criteria.

Risk assessment for a patient with an eating disorder should include identification of:

  • medical instability and risk of hospitalisation;
  • level of psychological distress and suicide risk;
  • level of malnourishment;
  • identification of psychiatric comorbidity;
  • level of disability;
  • duration of illness;
  • response to earlier evidence-based eating disorders treatment;
  • level of family/carer support.
     

Where a consultant psychiatrist provides an EDP service, the service must also include:

  • administering an outcome measurement tool, where clinically appropriate. The choice of outcome tool to be used is at the clinical discretion of the practitioner. Practitioners using such tools should be familiar with their appropriate clinical use, and if not, should seek appropriate education and training; and
  • conducting a mental state examination.

Consultation with the patient’s managing practitioner

A written copy of the EDP should be provided to the patient’s managing 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 managing practitioner may be appropriate.

 Additional Claiming Information (general conditions and limitations)

Patients seeking rebates for items 90250-90257 and 90260-90263 will not be eligible if the patient has had a claim within the last 12 months.

Items 90250-90257 cannot be claimed with Items 2713, 279, 735, 758, 235 and 244. Items 90261 and 90263 cannot be claimed with Items 110, 116, 119, 132, 133.

Consultant psychiatrist and paediatrician EDP items 90260-90263 do not apply if the patient does not have a referral within the period of validity.

Before proceeding with the EDP the medical practitioner must ensure that:

(a) the steps involved in providing the service are explained to the patient and (if appropriate and with the patient's permission) to the patient's carer; and

(b) the patient's agreement to proceed is recorded.

The medical practitioner must offer the patient a copy of the EDP and add the document to the patient's records. This should include, subject to the patient's agreement, offering a copy to their carer, where appropriate. The medical practitioner may, with the permission of the patient, provide a copy of the EDP, or relevant parts of the plan, to other providers involved in the patient's treatment.

The medical practitioner EDP cover the service of developing an EDP. A separate consultation item can be performed with the EDP if the patient is treated for an unrelated condition to their eating disorder. Where a separate consultation is performed, it should be annotated separately on the patient’s account that a separate consultation was clinically required/indicated.

All consultations conducted as part of the EDP must be rendered by the medical practitioner and include a personal attendance with the patient. A specialist mental health nurse, other allied health practitioner, Aboriginal and Torres Strait Islander health practitioner or Aboriginal Health Worker with appropriate mental health qualifications and training may provide general assistance to the medical practitioner in provision of this care.

Additional Claiming Information (interaction with Chronic Disease Management and Better Access)

It is preferable that wherever possible patients have only one plan for primary care management of their disorder. As a general principle the creation of multiple plans should be avoided, unless the patient clearly requires an additional plan for the management of a separate medical condition.

The Chronic Disease Management (CDM) care plan items (items 721, 723, 729, 731 and 732) continue to be available for patients with chronic medical conditions, including patients with complex needs.

Where a patient has a separate chronic medical condition, it may be appropriate to manage the patient's medical condition through a CDM Plan, and to manage their eating disorder through an EDP. In this case, both items can be used. Where the patient receives dietetic services under the CDM arrangements (item 10954), these services will count towards the patients maximum of 20 dietetic services in a 12 month period.

Where a patient has other psychiatric comorbidities, these conditions should be managed under the EDP. Once a patient has a claim for an EDP, the patient should not be able to have a claim for the development or review of a Mental Health Treatment plan by a GP (items 2700, 2701, 2715 and 2717) or medical practitioner in general practice (items 272, 276, 281 and 282) within 12 months of their EDP unless there are exceptional circumstances.

For the purpose of the 40 EDPT count; eating disorder psychological treatment service includes a service under provided under the following items: 90271, 90272, 90273, 90274, 90275, 90276, 90277, 90278, 90279, 90280, 90281, 90282, 2721, 2723, 2725, 2727, 283, 285, 286, 287, 371, 372 and items in Groups M6, M7 and M16 (excluding items 82350 and 82351).

 

Related Items: 90250 90251 90252 90253 90254 90255 90256 90257 90260 90261 90262 90263


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