Medicare Benefits Schedule - Item 91221

Search Results for Item 91221

View Associated Notes

Category 8 - MISCELLANEOUS SERVICES

91221

91221 - Additional Information

Item Start Date:
13-Mar-2020
Description Updated:
20-Apr-2020
Schedule Fee Updated:
01-Jul-2022

Group
M19 - Midwifery telehealth and phone services
Subgroup
2 - Midwifery phone services

Short postnatal phone attendance by a participating midwife, lasting up to 40 minutes.

 

Fee: $56.45 Benefit: 85% = $48.00

(See para MN.13.15, MN.13.16, MN.13.17, MN.13.18 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $169.35


Associated Notes

Category 8 - MISCELLANEOUS SERVICES

MN.13.15

Overview of the Maternity Items

Face to Face Services

Antenatal, intrapartum and postnatal care provided by participating midwives are covered by MBS items 82100, 82105, 82110, 82115, 82116, 82118, 82120, 82123, 82125, 82127, 82130, 82135, 82140.  These items cover 13 specific types of service that allow the participating midwife to: 

  • undertake an initial antenatal attendance of more than 40 minutes duration (item 82100);
  • provide a short antenatal attendance of up to 40 minutes duration (item 82105);
  • provide a long antenatal attendance of more than 40 minutes duration (item 82110);
  • make an assessment of and prepare a maternity care plan for a patient across a pregnancy that has progressed beyond 28 weeks and there have been at least two antenatal attendances with the claiming participating midwife in the preceding six months (item 82115); 
  • undertake management of labour (excluding birth) out of hospital for up to 6 hours (item 82116);
  • undertake management of labour (including birth where performed or attendance and immediate post-birth care at an elective caesarean section) in hospital by the first participating midwife for a total of up to 6 hours (item 82118);
  • undertake management of labour (including birth where performed) by the first participating midwife for a total of 6 to 12 hours, including birth (item 82120);
  • undertake management of labour (including birth where performed) in hospital by the second participating midwife for a total of up to 6 hours (item 82123);
  • undertake management of labour (including birth where performed) by the second participating midwife for a total of 6 to 12 hours including birth (item 82125);
  • undertake management of labour (including birth where performed) in hospital by the third participating midwife for a total of up to 6 hours (item 82127);
  • provide a short postnatal attendance of up to 40 minutes duration (item 82130);
  • provide long postnatal attendance of at least 40 minutes duration (item 82135); and
  • provide a comprehensive postnatal check to a patient 6 weeks after the birth of the baby (item 82140).

Telehealth Services

  • A service may only be provided by telehealth where it is safe and clinically appropriate to do so.
  • These MBS telehealth items are for out-of-hospital patients.
  • Providers are expected to obtain informed financial consent from patients prior to providing the service including providing details regarding their fees and any out-of-pocket costs.

The participating midwife telehealth items are:

Service Telehealth items via video-conference Telephone items for when video-conferencing is not available
Short antenatal attendance lasting up to 40 minutes 91211 91218
Long antenatal attendance lasting at least 40 minutes 91212 91219
Short postnatal attendance lasting up to 40 minutes 91214 91221
Long postnatal attendance lasting at least 40 minutes 91215 91222

Related Items: 82100 82105 82110 82115 82116 82118 82120 82123 82125 82127 82130 82135 82140 91211 91212 91214 91215 91218 91219 91221 91222

Category 8 - MISCELLANEOUS SERVICES

MN.13.16

Maternity Services Attracting Medicare Rebates

Medicare Benefits are only payable for clinically relevant services. Clinically relevant in relation to midwifery care means a service generally accepted by the midwifery profession as necessary to the appropriate treatment of the patient's clinical condition. 

Medicare benefits are only payable where the participating midwife provides care to not more than one patient on the one occasion.  

Antenatal Care

Eligible maternity care plan service

MBS item 82115 is the one MBS item available for participating midwife practitioners to undertake a comprehensive assessment and prepare a written maternity care plan for a patient, who is not an admitted patient of a hospital, across a pregnancy that has progressed beyond 28 weeks. In order to claim item 82115, the participating midwife is required to have had at least two antenatal attendances (82105, 82110, 91211, 91212, 91218 or 91219) with the patient in the preceding six months; and the provider who undertakes the care plan should intend to remain the primary health care provider for the remainder of the pregnancy.

There will be a six month transition period for the restriction on the claiming participating midwife having at least two antenatal attendances in the preceding six months. This transition period acknowledges that in the six months prior to 1 March 2022 (before this requirement was legislated), participating midwives may not have had the required two antenatal visits with the patient to claim 82115 as at the time they were not aware of the upcoming requirement. The transition period will end on 1 September 2022.

For example, if 82115 is provided on 1 April 2022 and only one antenatal attendance by the same participating midwife was provided in the past 6 months, then claiming item 82115 will still be permitted. If this same scenario occurs on 1 September 2022, then the claim would not be permitted.

It is expected that the care plan would be agreed with the patient and detail such things as agreed expectation, health problems and care needs and appropriate referrals, medication and diagnostic tests.   

This item cannot be claimed if items 16590 or 16591 have previously been claimed during a single pregnancy, except in exceptional circumstances. An exceptional circumstance in which the creation of a new maternity care plan may be required includes a significant change in the patient's clinical condition or maternity care requirements.

For claiming purposes, the exceptional circumstance requiring another maternity care plan needs to be recorded in the patient’s notes, and “exceptional circumstance” notated when submitting the claim.

Number of services: Only one (1) midwifery care plan (82115) is payable in any pregnancy. 

Antenatal Attendances

Medicare benefits are payable for an antenatal service where a participating midwife provides a clinically relevant service in respect of a miscarriage. Medicare benefits are not payable for an antenatal attendance associated with the labour. The labour items (82116-82127) include all associated intrapartum attendances. 

Any clinically relevant indication that requires an antenatal attendance by a participating midwife on an admitted patient in hospital, but that is not associated with the labour, will attract a Medicare benefit. 

Number of services: Only one (1) initial antenatal attendance under item 82100 is payable in any pregnancy. There is no limit attached to long and short antenatal attendances (82105, 82110, 91211, 91212, 91218 and 91219) by a participating midwife. However, only clinically relevant attendances should be itemised under Medicare and services provided by participating midwives will be subject to Medicare Audit and Professional Review Processes.  

Management of labour

The MBS includes six items for management of labour by a participating midwife;   

  • undertake management of labour (excluding birth) out of hospital for up to 6 hours (item 82116)
  • undertake management of labour  (including birth where performed or attendance and immediate post-birth care at an elective caesarean section) in hospital by the first participating midwife for a total of up to 6 hours (item 82118)
  • undertake management of labour (including birth where performed) by the first participating midwife for a total of 6 to 12 hours, including birth (item 82120)
  • undertake management of labour (including birth where performed)  in hospital by the second participating midwife for a total of up to 6 hours (item 82123)
  • undertake management of labour (including birth where performed) by the second participating midwife for a total of 6 to 12 hours including birth (item 82125)
  • undertake management of labour (including birth where performed) in hospital by the third participating midwife for a total of up to 6 hours (item 82127)

Management of labour out of hospital

Item 82116 is for the management of labour out of hospital for up to six hours. This item is intended to provide benefits for patients whose births occur in hospital. This item is not intended to provide benefits for planned home births.

This item is not claimable if the management of labour and birth is intended to be transferred to an obstetrician, medical practitioner or non-participating midwife. The total attendance time is to be documented in the patient notes.

Management of labour in hospital

The intrapartum items (82118-82127) are claimable for the participating midwife’s total attendance managing the patient’s labour in hospital. These items are claimable from when the patient is admitted to hospital. The time taken to conduct a patient handover to another participating midwife is counted towards the total attendance. Breaks taken to manage the participating midwife’s fatigue are not counted towards the total claimable time. The total attendance time for each participating midwife is to be documented in the patient notes.

Example One:

  • The first participating midwife manages the patient’s labour at the patient’s home for five hours and then for three hours in hospital. To manage their fatigue, the first participating midwife hands over care to a second participating midwife and takes a 10 hour break.
  • The second participating midwife takes over the patient’s care and manages the labour for 10 hours before handing over care to the first participating midwife to manage their own fatigue.
  • The first participating midwife takes over the patient’s care and manages their labour and birth for 6 hours.

In this scenario, the first participating midwife would be eligible to claim 82116 (for the five hours in attendance out of hospital) and 82120 (for the total of nine hours in hospital attendance). The second participating midwife would claim 82125 (for the total of 10 hours in hospital attendance).

Example Two:

  • The first participating midwife manages the patient’s labour in hospital for two hours and as they have been at another birth just prior to this attendance, needs to take a break to manage their fatigue. They handover the patient’s care to the second participating midwife before taking a 10 hour break.
  • The second participating midwife takes over the patient’s care and manages the labour in hospital for six hours before handing over care to the third participating midwife to manage their fatigue.
  • The third participating midwife takes over the patient’s care. The third midwife has already managed a different patient’s labour and birth earlier that day and is able to manage this patient’s labour for four hours before handing over care to the first participating midwife to manage their fatigue.
  • The first participating midwife manages the labour and birth for four hours.

In this scenario, the first participating midwife would claim 82118 (for the six hours in hospital attendance). The second participating midwife would claim 82123 (for the six hours in hospital attendance) and the third participating midwife would claim 82127 (for the four hours in hospital attendance).

Medicare benefits are payable under items 82118-82127 whether or not the participating midwife undertakes the birth i.e. including where the patient’s care is escalated to an obstetrician during labour or for the birth. 

Medicare benefits are only payable where the service is provided to an admitted patient of a hospital, including a hospital birthing centre. Labour is taken to commence when the participating midwife attends a patient that is in labour and who has been admitted to the hospital for labour and birth. The time period for these items is the period for which the participating midwife is in exclusive attendance on the patient for labour, and birth where performed. 

Medicare benefits are only payable for management of labour where the participating midwife undertaking the service has provided the patient's antenatal care or who is a member of a practice that provided the patient's antenatal care. 

It is not intended that these items be claimed routinely by participating midwives who do not intend to undertake the birth i.e. where the participating midwife has arranged beforehand for a medical practitioner to undertake the birth. Where the participating midwife does not undertake the birth it is because:

  • In order to manage the participating midwife’s fatigue, care was transferred to another participating midwife for management of labour; or
  • There was a clinical need to escalate care to an obstetrician or medical practitioner who provides obstetric services.

Number of services: Intrapartum items 82116-82127 can only be claimed once per pregnancy.

Postnatal Care

In addition to the long and short antenatal attendance items for postnatal care in the first six weeks post birth, the MBS provides for a six week postnatal check (82140), after which the patient would be referred back to a GP. 

Number of services: Only one (1) postnatal check (82140) by a participating midwife is payable in any pregnancy. 

There is no limit attached to long and short postnatal attendances (82130, 82135, 91214, 91215, 91221 and 91222) by a participating midwife. However, only clinically relevant attendances should be itemised under Medicare and services provided by participating midwives will be subject to Medicare Audit and Professional Review Processes. 

Related Items: 82100 82105 82110 82115 82116 82118 82120 82123 82125 82127 82130 82135 82140 91211 91212 91214 91215 91218 91219 91221 91222

Category 8 - MISCELLANEOUS SERVICES

MN.13.17

Conditions Governing the Provision and Claiming of Items

 Service length and type

  • Services under these items must be for the time period specified within the item descriptor.  
  • Professional attendance for MBS items 82100, 82105, 82110, 82115, 82116, 82130, 82135 and 82140 may be provided in an appropriate setting that includes but is not limited to: the patient’s home, a midwifery group practice, a participating midwife practitioner's rooms or a medical practice.
  • Items 91211, 91212, 91214, 91215 are telehealth items provided via video-conference and items 91218, 91219, 91221 and 91222 are telephone items provided when video-conferencing is not available.

Related Items: 82100 82105 82110 82115 82116 82118 82120 82123 82125 82127 82130 82135 82140 91211 91212 91214 91215 91218 91219 91221 91222

Category 8 - MISCELLANEOUS SERVICES

MN.13.18

Referral Requirements

A participating midwife will be able to refer a patient to specialist obstetricians and paediatricians as clinical services dictate. 

This measure does not include referral by a participating midwife for allied health care. If a participating midwife refers a patient to an allied health practitioner, no benefits would be payable for that service. 

Medicare benefits are not payable specifically for services provided by a lactation consultant at this time. Medicare benefits would be payable for breast feeding support provide as part of the postnatal care by the participating midwife. 

A referral is valid for 12 months to cover the labour (antenatal, birthing and postnatal care for 6 weeks post birth). Should there be a new pregnancy in that period, a new referral will be required. 

A new pregnancy represents a new episode of care. 

A referral to a specialist must be in writing in the form of a letter or a note to the specialist and must be signed and dated by the referring participating midwife. The referral must contain any information relevant to the patient and the specialist must have received the referral on or prior to providing a specialist consultation. 

If a specialist provides a consultation without a referral, the specialist's consultation would not attract Medicare benefits at the specialist rate. 

There are exemptions from this requirement in an emergency if the participating midwife considers the patient's condition requires immediate attention without a referral. In that situation, the specialist must decide that it is necessary in the patient’s interests to render the professional service specified in the item as soon as practicable and they must begin rendering a service within 30 minute of the patient’s presentation. If a referral is lost, stolen or destroyed, the participating midwife would need to provide a replacement referral as soon as is practicable after the service is provided. 

If the patient is a privately admitted patient of a hospital a letter or note is not required. The referring participating midwife would make a notation in the patient’s notes, which they would sign, approving the referral. 

A referral is not required to transfer a patient’s care during the intra-partum period under items 16527 and 16528.  The participating midwife would make a signed notation in the patient’s notes approving the transfer of care. 

A referral is not required to refer the patient back to their GP after the six week postnatal period.  The participating midwife would provide a discharge summary to the GP outlining the maternity history and any relevant clinical issues, which would also be recorded on the patient's notes.

Related Items: 82100 82105 82110 82115 82116 82118 82120 82123 82125 82127 82130 82135 82140 91211 91212 91214 91215 91218 91219 91221 91222


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